* Required Information

Complete the form below to enroll your camper or counselor in the medication blister pack program(Dispill). One enrollment per camper or counselor registered and confirmed to attend Camp Onas.


I enroll the camper / counselor list above in the medication blister pack program (Dispill) with Horsham Pharmacy.

I authorize Horsham Pharmacy to use information I provided to Camp Onas for prescriptions


Please list all prescription medications that you would like Horsham Pharmacy to dispense in the daily blister package.

Medication Strength Direction Prescription Doctor (Primary or Specialist) Special Instruction(Example: Brand or generic)

Please list all over-the-counter medications (OTC) and / or vitamins that you would like Horsham Pharmacy to dispense in the daily blister package. The pharmacist will call back to verify and confirm costs to add to blister packs.

Medication Name Strength Dosage Form(Example: Capsule, table, etc) Direction Special Instruction(Example: Brand or generic)

Provide prescription insurance information that can be found on the camper or primary plan holder prescription benefit card. (Skip if you already provided to Camp Onas or if you're submitting a copy)