NJY Camper Registration - Keystone Pharmacy

Step 1: Keystone Professional Pharmacy - NJY Camps Registration Form

NJY Camps Registration Form. Reminder there is a $75 registration fee per child. (plus $30 late fee after 6/1 for 1st sessions and $30 late fee after 7/1 for 2nd sessions). There is a discounted registration fee for more than 3 campers in one family.

Parent/Legal Guardian Full Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phones(Required)

Cell Phone

Home Phone

Email of Parent(Required)

Insured(Required)

Insured Name (Subscriber)

DOB (Subscriber)

Prescription Plan(Required)

Name of Prescription Plan

Prescription Plan Phone

Prescription Member Info(Required)

Member/ID#

RxBin#

RxPCN#

RxGroup#

Secondary Insurance (If Applicable)

Secondary Insurance

Secondary Insurance Phone

Secondary Insurance Member (if applicable)

(2nd) Member/ID#

(2nd) RxBin#

(2nd) RxPCN#

(2nd) RxGroup#

Please Upload Prescription Plan Card Here (Front AND Back Please)

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 12 GB, Max. files: 5.

Pharmacy

Current Pharmacy Name

Phone Number

Mail-Order Pharmacy (if applicable)

Does your Rx Plan require mailorder?

If mailorder required, does your Rx Plan allow refills outside of mailorder pharmacy network?

Do you use a coupon for your med fills?

(If Yes, please upload coupon below)

If you use a coupon for med fills, please upload here:

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 12 GB, Max. files: 5.

Billing Address (if different than home address)

Street Address Address Line 2 City State ZIP Code

Please Add All Campers Below

Camper

Camper Name	Select Camp	Camper DOB	Camper Gender Assigned at Birth	Medication Allergies	Existing Medication (for insurance verification)	Actions

There are no Campers.

(Please add information for each Camper. Use the button above to add each child.)