Parent / Guardian Information

















Payment Section





       

       
(Registration Fee will be charged to credit card within 72 hours of registration.)








I acknowledge and assume responsibility and grant authorization for Campers Pharmacy / Valley Pharmacy and/or its parent company or affiliates to charge the above credit card for registration and sign-up fees where applicable. I also acknowledge responsibility for the cost of any medication not covered by my insurance company, for any medication that Campers Pharmacy / Valley Pharmacy cannot get reimbursement for, as well as any co-insurance and deductibles and charges for OTC/Sundries which I agree will be billed to my credit card by Campers Pharmacy. I authorize Campers Pharmacy / Valley Pharmacy to contact my insurance company for verification of coverage, billing, and collections for my medications. As per our HIPAA agreement, all personal information received will be solely maintained for the purposes of dispensing prescriptions and insurance collection.


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I acknowledge that I have read and understand the following.


1. The registration fee is non-refundable

2. All Controlled Drug Prescriptions should be written out for up to 30 days supply ONLY. If your child is attending camp for more than 30 days, a separate prescription is required for each 30 day period.

3. DO NOT FILL BEFORE date on controlled drug prescriptions should be 2 weeks prior to start of session.

4. All OTC'S require a prescription written by the physician.

5. All prescriptions should be written for the time of day the medicine is to be administered to the camper ( i.e. breakfast, lunch, dinner,bedtime).If the medicine is taken as needed please make sure it is specified on the prescription.

6. All prescriptions will be filled generically (if available) unless otherwise specified by your physician as Do Not Substitute

7. All prescriptions must be received by the pharmacy at least 3 weeks prior to the start of the session or a late fee of $5.00 will be charged.

8. Please upload copies of all prescription insurance cards to avoid delays in processing.

9. I have read a copy of Valley Pharmacy’s HIPPA policy.

CANCEL