Step 1: Keystone Professional Pharmacy - Muss Trip Registration Form Muss School Trip Registration Form. Reminder there is a $150 registration fee per child. (plus $15 late fee after 6/13 and $30 late fee after 6/16)Parent/Legal Guardian Full Name(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phones(Required)Cell PhoneHome Phone Add RemoveEmail of Parent(Required) Insured(Required)Insured Name (Subscriber)DOB (Subscriber) Add RemovePrescription Plan(Required)Name of Prescription PlanPrescription Plan Phone Add RemovePrescription Member Info(Required)Member/ID#RxBin#RxPCN#RxGroup#Secondary Insurance (If Applicable)Secondary InsuranceSecondary Insurance PhoneSecondary 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 Select files Accepted file types: jpg, png, pdf, Max. file size: 64 MB, Max. files: 5. PharmacyCurrent Pharmacy NamePhone NumberMail-Order Pharmacy (if applicable) Add RemoveDoes your Rx Plan require mailorder?Please SelectYesNoIf mailorder required, does your Rx Plan allow refills outside of mailorder pharmacy network?Please SelectYesNoN/A or Mailorder Not RequiredDo you use a coupon for your med fills?Please SelectYesNo(If Yes, please upload coupon below)If you use a coupon for med fills, please upload here: Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 64 MB, Max. files: 5. Billing Address (if different than home address) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Please Add All Students BelowStudents Student Name Select School Select Session Student DOB Student Gender Assigned at Birth Medication Allergies Existing Medication (for insurance verification) Actions Edit Delete There are no Students. Add Student Maximum number of students reached. (Please add information for each Student. Use the button above to add each child.)Consent(Required) I agree to the following:I acknowledge that I am responsible for the cost of any medication not covered by my insurance company, for any medication for which the pharmacy does not get reimbursed, for any medication for which the pharmacy gets reimbursed less than their actual cost, as well as any co-payments and deductibles, which I agree will be billed directly to my credit card by the pharmacy. If I am submitting insurance information, I agree to authorize the pharmacy to contact my insurance company for insurance verification, billing and collections for my child's medications. Our licensed pharmacies are HIPPA compliant and all personal information received will be solely maintained for the purpose of dispensing medication and insurance collection. I acknowledge that I will be billed a $150 registration fee per child upon completion of this form, any LATE FEES, and any corresponding Fedex / delivery fees if the required items are not received prior to the deadlines. $15 late fee after 6/13 and $30 late fee after 6/16.
