Camp Barney – Arnold Drug Co.

Please submit this form by

May 13 for all Session 1 campers (this includes Kochavim A and B, Youth A and B, CBM Experience, Chalutzim, and Chalutzim Experience)
June 10 for all Session 2 campers (this includes Kochavim C and D)

Please send a copy of the following

A photocopy of both the front and back of your child’s insurance medication card to rx@arnolddrugs.net

For prescriptions unable to be sent electronically, the physician may call them in to Arnold's (706-778-4918) where legally allowed or they can be mailed to us at 639 Irvin Street, Cornelia GA 30554.

Camper First Name

Camper Last Name

Date of Birth

Phone Number

Address

Apt, suite, etc.

Country

City

State

Zip code

List your child's prescriptions:

Medication

Dose

Frequency

Generics Okay?

Medication

Dose

Frequency

Generics Okay?

Medication

Dose

Frequency

Generics Okay?

Medication

Dose

Frequency

Generics Okay?

Medication

Dose

Frequency

Generics Okay?

If you need to list more prescriptions, you can list them here. (Please use the same format as above)

If you have any special instructions, you can list them here.

My Child is allergic to the following drugs:

Primary Insured's Name

Primary Insured's Address Insurance Company

Policy #

A credit card number is needed by Arnold Drug to charge for your co-pay and the $40 per camper packaging fee. Please provide the following information below:

Credit Card Holder

Card Holder Phone Number

Card Type

Card Number

Expiration Date

CVV#

Zip Code

I hereby authorize Arnold Drug Company to charge the above credit card for my insurance co-pay (or the price for the medication if my insurance plan does not accept the submission by Arnold Drug Company) and a $40 fee for packaging our prescription order.

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Reset Signature

Date

Parent Email

To notify you that Arnold Drug received this form

Parent Phone Number

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