General Information

If you are submitting a new registration, submit both forms (registration and payment) on this page and the following page.
Registrations submitted without payment information will not be processed.

Registration Form

Start

Select an option to begin:

This is a new registration for 2023.
I need to update a previously submitted registration.
I need to cancel a registration.

Modify.

Select as many options as apply to modify
those sections of the registration form.

When finished, click the submit button to update.

Cancel.

Enter the name of the camper whose registration you wish to cancel, then click submit.

What needs to be updated?

Camper name/DOB/medication allergies.
Parent contact information.
Camp name and/or dates.
Prescription Medications.
OTCs/melatonin/vitamins/supplements.
Insurance.
Credit card or HSA/FSA card.

Click this link to be transferred directly to the payment form!

Instructions.

Please read each section carefully before submitting this form.

We strongly recommend completing this form on a laptop or desktop computer rather than a mobile device or tablet.

This year, we are using a standardized formulary for certain medications (namely OTCs, vitamins, and dietary supplements) to streamline our operations and minimize errors and ambiguity in the registrations we receive.

All medications will be filled generically, if a therapeutically equivalent alternative is available.

Spaces are included for items not listed on our formulary, if they are critically important and cannot be substituted. In such instances, you must send a sufficient supply to the Pharmacy for packaging.

Only one option may be selected for each multiple-choice answer.

Select as many checkbox options as appropriate for checkbox-style answers.

You will receive an email confirmation with your selections after submitting this form.

If you need to make a correction, or if prescription therapy changes after submission, select the appropriate option at the top of the page to submit only the updated information.

Don't forget to also submit the Payment Information Form at the end of this page.

Both are required for new registrations!

Important Deadlines:

February 1: Registration opens.

April 10: Last day for early registration, fee increases to $50 starting 4/11.

May 10: Last day for standard registration, fee increases to $55 starting 5/11.

June 10: Final registration deadline, fee increases to $95 starting 6/11.

June 10: Regular prescription deadline. Prescriptions for non-controlled medications must be received by 6/10.

June 10: Mailed-in items deadline. Any items mailed from home for repackaging must be received by 6/10.

June 19: CII Prescription deadline. Final date for any CII prescriptions to be received.

If you have any questions about this form, please contact us at (845) 887-3030 ext 8.

Section 1: Basic Information.

Demographics

Camper Name *

First

Last

Date of Birth *

Medication Allergies? *

Medication Allergies

Please include all medication allergies, including the type of reaction and severity (e.g. sulfa antibiotics, whole body rash).

Parent/Guardian Name *

First

Last

Home Address *

Address Line 1

City

State

Zip Code

Email *

Confirm Email

Telephone (mobile preferred) *

Section 2: Camp Selection and Dates.

Camp

Camp Attending: *

Camp Equinunk
Camp Blue Ridge
Camp IHC
Tyler Hill Camp
French Woods

Duration: *

Full (6/25 to 8/12)
Other

Duration: *

Full (6/24 to 8/12)
Other

Duration: *

Full (6/24 to 8/11)
Other

First Day *

Last Day *

Section 3: Types of Medications Taken.

Types of Medications Taken *

Schedule II controlled substance prescriptions (Section 4).
Regular prescriptions (Section 5).
OTC medications (Section 6).
Melatonin, vitamins, minerals, and/or dietary supplements (Section 7).
None!

Select all that apply, then scroll to the appropriate section(s) below to complete.

No meds!

If no medications, OTCs, vitamins, or dietary supplements are taken on a regularly scheduled basis, completion of this registration form is optional!
You may continue below to update insurance and payment information if you wish, in the event it is needed in the future for acute medications (e.g. antibiotics, antihistamines, eye/ear drops, etc).

Section 4: CII Prescriptions.

Use the following section to add prescription medications that are also schedule II (CII) controlled substances.

Schedule II is the DEA's list of most strictly controlled pharmaceuticals used outside of research settings, and thus are separated here from non-CII medications.

A more comprehensive explanation of CII controlled substances can be found at this link.

CII prescriptions must be received by the Pharmacy no later than June 19th to ensure they are packaged and delivered on time.

The date of delivery submitted to the NYS Prescription Monitoring Program will not be earlier than June 21st. All CII prescriptions will be held at the Pharmacy until that date at the earliest.

Section 1: Controlled Substances

Long-Acting Stimulants *

Adderall XR
Concerta
Focalin XR
Metadate CD
Ritalin LA
Vyvanse
Other, Not Listed
None

Short-Acting Stimulants *

Adderall
Ritalin
Focalin
Other, Not Listed
None

Adderall XR *

Concerta *

Focalin XR *

Metadate CD *

Ritalin LA *

Vyvanse *

Unlisted Long-Acting Drug *

Unlisted items must be mailed to the Pharmacy!

Adderall IR *

Ritalin IR *

Focalin IR *

Unlisted Short-Acting Drug *

Unlisted items must be mailed to the Pharmacy!

Adderall = mixed amphetamine salts.

Adderall XR = extended-release mixed amphetamine salts.

Concerta = extended-release methylphenidate tablet.

Focalin = DEXmethylphenidate.

Focalin XR = extended-release DEXmethylphenidate.

Metadate = extended-release methylphenidate capsule.
CD = Controlled Dispersion.

Ritalin LA = extended-release methylphenidate capsule.
LA = Long Acting.

Vyvanse = lisDEXamfetamine.

Ritalin = methylphenidate.

Time Taken (Long-Acting) *

AM
Noon
PM
Other

Time Taken (Long-Acting ext) *

As needed
Noon
Bedtime

Time Taken (Short-Acting) *

AM
Noon
PM
Other

Time Taken (Short-Acting ext) *

As needed
Noon
Bedtime

Availability:

If your home pharmacy has recently been experiencing difficulty obtaining your child's medications, our suppliers are also likely to be similarly impacted. Please let us know if supply has been an issue within the last several months.

Section 5: Non-Controlled Substance Prescriptions.

Use the following section to add any other prescription medications that are NOT schedule II controlled substances.

OTCs, melatonin, vitamins, and supplements are added in the following sections, if needed.

Prescriptions must be received by the Pharmacy no later than June 10th.

Drug Name #1

Drug Strength *

Dose *

Time(s) Taken *

AM
PM
Bedtime
As needed
Other

Time(s) Taken (ext 1) *

Noon
Every OTHER day
Once weekly
Twice weekly
Monthly

Drug Name #2

Drug Strength *

Dose *

Time(s) Taken *

AM
PM
Bedtime
As needed
Other

Time(s) Taken (ext 2) *

Noon
Every OTHER day
Once weekly
Twice weekly
Monthly

Drug Name #3

Drug Strength *

Dose *

Time(s) Taken *

AM
PM
Bedtime
As needed
Other

Time(s) Taken (ext 3) *

Noon
Every OTHER day
Once weekly
Twice weekly
Monthly

Drug Name #4

Drug Strength *

Dose *

Time(s) Taken *

AM
PM
Bedtime
As needed
Other

Time(s) Taken (ext 4) *

Noon
Every OTHER day
Once weekly
Twice weekly
Monthly

Drug Name #5

Drug Strength *

Dose *

Time(s) Taken *

AM
PM
Bedtime
As needed
Other

Time(s) Taken (ext 5) *

Noon
Every OTHER day
Once weekly
Twice weekly
Monthly

Drug Name #6

Drug Strength *

Dose *

Time(s) Taken *

AM
PM
Bedtime
As needed
Other

Time(s) Taken (ext 6) *

Noon
Every OTHER day
Once weekly
Twice weekly
Monthly

Drug Name #7

Drug Strength *

Dose *

Time(s) Taken *

AM
PM
Bedtime
As needed
Other

Time(s) Taken (ext 7) *

Noon
Every OTHER day
Once weekly
Twice weekly
Monthly

Section 6: OTC Medications.

Use the following section to add OTC items, if any.
Select as many administration times as may apply for each item.

Antihistamines

Oral Antihistamines

Zyrtec
Xyzal
Claritin
Allegra
Benadryl
(None)

Zyrtec Form & Strength *

Xyzal Form & Strength *

Claritin Form & Strength *

Allegra Form & Strength *

Benadryl Form & Strength *

Antihistamine Time Taken *

AM
Noon
PM
Bedtime
As needed

Limited availability:

Some chewable, dissolvable, and liquid antihistamines may become unavailable during the spring and summer due to manufacturer shortage or recall.
If the particular item you selected is backordered, it will automatically be switched to the next closest alternative at the pharmacist's discretion (e.g. Claritin Reditabs substituted for Zyrtec Dissolve).

Nasal and Ocular Antihistamines

Nasal Sprays

Corticosteroids
Miscellaneous
(None)

Corticosteroid *

Other *

Corticosteroid Time Taken *

AM
Noon
PM
Bedtime
As needed

Other Time Taken *

AM
Noon
PM
Bedtime
As needed

Eyedrops

Antihistamines
Decongestants
Lubricants
Other, not listed (1)
Other, not listed (2)
(None)

Antihistamine *

Decongestant *

Lubricant *

Unlisted Item 1

Unlisted items must be mailed to the Pharmacy!

Unlisted Item 2

Unlisted items must be mailed to the Pharmacy!

Antihistamine Time Taken *

AM
Noon
PM
Bedtime
As needed

Decongestant Time Taken *

AM
Noon
PM
Bedtime
As needed

Lubricant Time Taken *

AM
Noon
PM
Bedtime
As needed

Unlisted Item 1 Time Taken *

AM
Noon
PM
Bedtime
As needed

Unlisted Item 2 Time Taken *

AM
Noon
PM
Bedtime
As needed

NOTE: Unlisted items mailed to the Pharmacy for repackaging do NOT require a covering prescription issued by your pediatrician.

Miscellaneous Items

Acetaminophen susp.
Acetaminophen tablet
Bisacodyl tablet
Docusate capsule
Ex-Lax chewable
Famotidine tablet
Ibuprofen susp.
Ibuprofen tablet
Miralax Powder
Omeprazole tablet
Other, not listed (1)
Other, not listed (2)
Senna tablet
Tums chewable

Amount taken per dose (APAP susp) *

Amount taken per dose (APAP tab) *

Amount taken per dose (Bisacodyl) *

Amount taken per dose (Docusate) *

Amount taken per dose (Ex-Lax) *

Amount taken per dose (Famotidine) *

Amount taken per dose (Ibuprofen susp) *

Amount taken per dose (Ibuprofen tab) *

Amount taken per dose (Miralax) *

Amount taken per dose (Omeprazole) *

Amount taken per dose (Senna) *

Amount taken per dose (Tums) *

Unlisted Item 1 *

Unlisted items must be mailed to the Pharmacy!

Unlisted Item 2 *

Unlisted items must be mailed to the Pharmacy!

Time Taken (APAP susp) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (APAP tab) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Bisacodyl) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Docusate) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Ex-Lax) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Famotidine) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Ibuprofen susp) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Ibuprofen tab) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Miralax) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Omeprazole) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Unlisted Item 1) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Unlisted Item 2) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Senna) *

AM
Noon
PM
Bedtime
As Needed

Time Taken (Tums) *

AM
Noon
PM
Bedtime
As Needed

NOTE: Unlisted items mailed to the Pharmacy for repackaging do NOT require a covering prescription issued by your pediatrician.

Limited availability:

Some chewable/dissolvable/liquid formulations may become unavailable during the spring and summer due to manufacturer shortage or recall.
If the particular item you selected is backordered, it will automatically be switched to the next closest alternative at the pharmacist's discretion.

Section 7: Melatonin, Vitamins, and Dietary Supplements.

Use the following section to add melatonin, vitamins, and dietary supplements.
Select as many administration times as may apply for each item.

Melatonin

Zarbees
Vicks Pure ZZZS
Vitafusion
Natrol
Other, Not Listed
(None)

Melatonin Form & Strength *

Unlisted items must be mailed to the Pharmacy!

Melatonin Time Taken *

PM
Bedtime
As needed

NOTE: Unlisted items mailed to the Pharmacy for repackaging do NOT require a covering prescription issued by your pediatrician.

Vitamins

Vitamin B
Vitamin C
Vitamin D
Vitamin D plus calcium
Vitamin E
Ferrous Sulfate
Magnesium Oxide
Other, Not Listed (1)
Other, Not Listed (2)

Vitamin B Strength & Dose *

Vitamin C Strength & Dose *

Vitamin D Strength & Dose *

Vitamin D/Ca Strength & Dose *

Vitamin E Strength & Dose *

Ferrous Sulfate Strength & Dose *

Magnesium Oxide Strength & Dose *

Unlisted Vitamin 1 *

Unlisted items must be mailed to the Pharmacy!

Unlisted Vitamin 2 *

Unlisted items must be mailed to the Pharmacy!

Vitamin B Time Taken *

AM
Noon
PM
Bedtime

Vitamin C Time Taken *

AM
Noon
PM
Bedtime

Vitamin D Time Taken *

AM
Noon
PM
Bedtime

Vitamin D/Ca Time Taken *

AM
Noon
PM
Bedtime

Vitamin E Time Taken *

AM
Noon
PM
Bedtime

Ferrous Sulfate Time Taken *

AM
Noon
PM
Bedtime

Magnesium Oxide Time Taken *

AM
Noon
PM
Bedtime
As needed

Unlisted Vitamin 1 Time Taken *

AM
Noon
PM
Bedtime
As needed

Unlisted Vitamin 2 Time Taken *

AM
Noon
PM
Bedtime
As needed

NOTE: Unlisted items mailed to the Pharmacy for repackaging do NOT require a covering prescription issued by your pediatrician.

Multivitamins

Daily Multivitamins

Lil' Critters Complete Gummy
Lil' Critters Immune-C Gummy
Teen Girls MVI (Michaels) Tablet
Flintstones Complete Gummy
Other, Not Listed
(None)

Amount taken per dose *

Unlisted Multivitamin *

Unlisted items must be mailed to the Pharmacy!

Time Taken *

AM
Noon
PM
Bedtime

NOTE: Unlisted items mailed to the Pharmacy for repackaging do NOT require a covering prescription issued by your pediatrician.

Daily Probiotics

Florajen4Kids Capsule
Align Gummy
Culturelle Chewable
Lil' Critters Fiber Gummy
Digestive Advantage Gummy
Florastor Capsule
Other, Not Listed
(None)

Amount taken per dose *

Unlisted Probiotic *

Unlisted items must be mailed to the Pharmacy!

Time Taken *

AM
Noon
PM
Bedtime

NOTE: Unlisted items mailed to the Pharmacy for repackaging do NOT require a covering prescription issued by your pediatrician.

Section 8: Insurance Information.

Multiple Choice *

I have prescription insurance.
I don't need prescription insurance for the items I've selected and would prefer not to include it.

Please upload an image of your prescription insurance card (front and back).
NOTE: Prescription insurance cards contain different information than medical insurance cards!
We need the following four prescription insurance processing numbers to submit an insurance claim:

RxBIN: six digit number (e.g. 004336).

Rx Group: alphanumeric sequence.

Rx PCN: alphanumeric sequence, not always present or used.

Rx ID: cardholder ID number, may be unique or shared among all policy members.

Insurance

Prescription Insurance Card - Front *

Click or drag a file to this area to upload.

Prescription Insurance Card - Back *

Click or drag a file to this area to upload.

Acknowledgements

Section 9: Terms and Acknowledgements.

Privacy Practices Acknowledgement *

I have read and agree to Riverside Remedies' Notice of Privacy Practices.

Prescription Acknowledgement *

I understand, acknowledge, and agree to the following: *

(1) It is my responsibility to communicate with my physician to prescribe my child's meds and have said prescriptions transmitted to Riverside Remedies no later than June 10th (for most items) or June 19th (for CII controlled substances).

(2) Riverside Remedies is not responsible for obtaining any new prescriptions from my physician on my behalf.

Home Pharmacy Acknowledgement *

I understand, acknowledge, and agree to the following: *

I understand that any prescriptions filled at my home pharmacy during the month of June MUST be short-filled (i.e. for a quantity LESS THAN a 30 day supply) to avoid duplicate insurance claims for medications dispensed by Riverside Remedies.

I have notified my home pharmacy that my child will be away for the duration of camp and to:

(1) temporarily suspend all automatic refills, and

(2) temporarily HOLD any new prescriptions that may be received,

until August 10th or they return home, whichever is sooner.

Insurance Reject Acknowledgement *

I understand, acknowledge, and agree to the following: *

(1) I understand that it is my responsibility to coordinate with my physician and insurance company to make sure that any medications prescribed for my child by my home physician are covered by insurance to my satisfaction.

(2) I understand that insurance companies limit the amount of medication covered per month, and that I must coordinate with my home pharmacy to prevent any "duplicate claim" or "refill too soon" rejections from occurring while my child is away at camp.

(3) I authorize Riverside Remedies to charge my credit card for any prescriptions copayments as determined by my insurance company.

(4) I understand that, in the event a prescription medication is not covered by insurance for any reason, including but not limited to duplicate claim rejections, refill too soon rejections, prior authorization rejections, or nonformulary drug rejections, I may be liable for the full cost of the medication.

(5) I authorize Riverside Remedies to collect any amount(s) owed for the good(s) and service(s) they have furnished, up to and including the full cost of any medications that are not covered by my insurance for any reason.

Unlisted Item Acknowledgement *

I understand, acknowledge, and agree to the following: *

(1) I understand that any UNLISTED items I have added above will NOT be supplied by Riverside Remedies, and that I am responsible for mailing those UNLISTED items to the Pharmacy for packaging and delivery.

(2) I understand that mailing said items after June 10th (for OTCs, vitamins, and dietary supplements) or June 19th (for CII controlled substance prescriptions) may cause their packaging and delivery to camp to be delayed, and that those items may not be delivered to camp until after my child has already arrived.