Camper Medication Form

We strongly encourage any liquid medications to be exchanged for oral disintegrating tablets (ODT) or chewables, this will help ensure proper administration of the medication. Liquid medication can easily spill and is difficult to safely carry while in outdoor excursions.

Due to medications being organized by bunk, siblings cannot share medications INCLUDING over the counter medications.  You must register each child individually, camp will not pull medications from one camper to give to sibling camper. Every camper that needs any prescription or over the counter medication must be registered here. NO SIBLING SHARING OF MEDICATIONS.

If more than one child is attending camp, complete a separate form for each camper. If you have any questions, call us at (951) 407-0707.

Please make sure to answer any YES/NO questions.

Payment Information: Perris Hills Pharmacy will contact you by phone to obtain credit card information.

Download the PDF version of Camper Medication Form here.

IMPORTANT Please read the Terms of Use and FAQ to understand the fees associated with 1) late registration and prescriptions, and 2) expedited shipping.

SECONDARY PARENT OR LEGAL GUARDIAN INFO
INSURANCE INFORMATION
Primary Insurance
Secondary insurance
MY CAMPER'S INFO
Type in your birth date in the appropriate section
*** PARENTS & GUARDIANS, MAKE SURE TO SELECT YOUR CAMPER'S SESSION AFTER YOU SELECT THE CAMP PROGRAM ***
 
CAMP TAWONGA - CAMPER'S PROGRAM
CAMP GILBOA - CAMPER'S PROGRAM
PRIMARY PHYSICIAN'S INFORMATION
MY CAMPER'S MEDICATIONS

Please list all medications (prescription, OTC, vitamins and supplements) that the camper is currently prescribed or is taking. Make sure you review your camper's Rx with your physician to confirm it is written exactly the way your camper takes the medication before sending to Perris Hills Pharmacy. We understand that this list might change as we approach camp season.

MEDICATIONS PRESCRIBED BY: Primary Physician

Enter all medications prescribed by your child's primary physician.

Medication 1
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

Do you have any special instructions for Camp?
Medication 2
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

Medication 3
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

Medication 4
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

Medication 5
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

Medication 6
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

Medication 7
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

Medication 8
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

Medication 9
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

Medication 10
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
If not generic enter your brand name

ENTER YOUR COPAY CARD INFO IF USING ONE

MEDICATIONS PRESCRIBED BY: Secondary physician orders, vitamins and supplements

Enter all medications prescribed by other physicians (that are not your child's primary physician). Make sure to add Physician's first name, last name, phone number and fax for each medication

Medication 1
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
Medication 2
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
Medication 3
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
Medication 4
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
Medication 5
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
Medication 6
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
Medication 7
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
Medication 8
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
Medication 9
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
Medication 10
Breakfast, Lunch, Dinner, Bedtime or As Needed/PRN
SPECIAL INSTRUCTIONS

A G R E E M E N T  
By clicking "Submit" you agree to Perris Hills Pharmacy's, My Kids Camp Meds TERMS OF USE and PRIVACY POLICY AGREEMENT.

Let the kids be kids and we will take care of their medications
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