Bear Care Service Request

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On Campus Mom Foundation

Email *

Form Submission Date:

YYYY

Requesting Party's Name: *

Is the requesting party a student or parent? *

Parent

Student

Other:

Requesting Party's Phone Number: *

Name of Person Receiving Service or Supplies: *

Location of Person Receiving Service or Supplies: *

Telephone Number of Person Receiving Service or Supplies: *

Supplies Requested:

Over-the-counter cold remedies

Over-the-counter cough remedies

Over-the-counter cough drops

Over-the-counter throat spray

Over-the-counter throat lozenges

Over-the-counter liquid acetaminophen

Over-the-counter tablet form acetaminophen

Over-the-counter ibuprofen

Over-the-counter liquid anti-diarrhea medication

Over-the-counter upset stomach, heartburn liquid bismuth subsalicylate

Pedialyte powder packets

Tissues

Prescription Pick Up Service Request:

CVS 820 S 5th St, Waco, TX 76706

Walgreens 1520 S Valley Mills Dr, Beverly Hills, TX 76711

Walgreens 9101 Woodway Dr, Woodway, TX 76712

HEB 1821 S Valley Mills Dr, Waco, TX 76711

Clear selection

Prescription Pick Up Additional Information Required:

Telephone Number Associated With Order

Date of Birth of Student

Medications listed above in most cases are of the generic form and do not require a prescription. Products are provided at no cost due to being provided either as a donation in kind or purchased utilizing foundational resources. Products are in the original manufacturer’s sealed carton and/or packaging.

Images of the requested items will be transmitted to the requesting party prior to packaging for delivery. Item(s) will then be packaged, labeled with the student’s name and delivered to the dorm desk or apartment location as specified on this form.

Parents and/or student’s may request item(s) not contained within this list of over-the-counter medications by purchasing those items online and selecting pick up by a member of our volunteer staff. The On Campus Mom Foundation, Inc. will facilitate delivery of those items to the dorm desk or apartment office location as indicated as the delivery location on this form.

The On Campus Mom Foundation, Inc. bears no liability in relationship to exceeding recommended daily dosage, allergic reactions or negative outcome from the ingestion of the products delivered.

I agree not to hold the On Campus Mom Foundation, Inc. liable for any negative outcome in relationship to this service request and products to be delivered.

Additional Comments:

A copy of your responses will be emailed to the address you provided.

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