If more than one child is attending camp, please complete a separate form for each camper. If you have any questions, call us at 1 (951) 407-0707.

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.

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.

INSURANCE INFORMATION
Please leave fields blank that do not apply.
Primary Insurance
Secondary Insurance
MY CAMPER'S INFO
The information of the child going to camp
In lbs.
Food, seasonal, etc
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.

MEDICATIONS PRESCRIBED BY: Other Physicians
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

SPECIAL INSTRUCTIONS
Or notes you might like to add.

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.