Arrive by midnight 6/23, (Check-in 6/23/22 3pm, check out on 6/26/22 10am)
Arrive by midnight 6/23, (Check-in 6/23/22 3pm, check out on 6/26/22 10am)
Arrive after 8am 6/24 , (Check-in 6/24/22 3pm, check out on 6/26/22 10am)
Arrive after 8am 6/24, (Check-in 6/24/22 3pm, check out on 6/26/22 10am)
Arrive 6/24, day visitor, no lodging, meals purchased on site
Arrive by midnight 6/23, (Check-in 6/23/22 3pm, check out on 6/26/22 10am)
Arrive by midnight 6/24, (Check-in 6/24/22, check out on 6/26/22 10am)
Emergency Health / Medical Information and Consent
In the event of an emergency, I, the undersigned parent/guardian of the child named on this form, hereby give
permission to COREM and their employees, agents, representatives, and adult volunteers, to arrange for and
authorize emergency medical, dental, or surgical treatment for my child, as considered necessary by the
attending physician. I wish to be advised prior to any further treatment by the hospital or doctor.Emergency Contact Information
I also agree to provide COREM with current telephone numbers at which I can be reached, as well as the
names and phone numbers of individuals who are likely to know where I am should an emergency arise. In the event of an emergency, if you are unable to reach me please contact:Medications and Non-Emergency Health Treatment
(Please sign/authorize all of the following authorizations/directions that are applicable.)
1. If my child becomes ill with symptoms that do not indicate emergency medical treatment (e.g., headache,
vomiting, sore throat, fever, diarrhea), I wish to be called (collect/reversed phone charges if necessary) to be
informed of my child’s condition.2. My child is currently taking the following medication(s), which he/she will bring on this activity, in well labeled,
original containers that include clear directions for dosage and frequency of use. I hereby give permission for an adult leader to administer the following medication(s):
3. No medication of any type (prescription or nonprescription) may be administered to my child unless his/her
condition is life-threatening and emergency treatment is required, as considered necessary by the attending
physician.
4. I hereby grant permission for nonprescription medication (e.g., non-aspirin pain relievers, throat lozenges,
cough syrup) to be given to my child, if deemed advisable by the adult supervisor of the activity, subject to the
following exceptions (write “none” if there are no specific exceptions):
Specific Medical Information/Conditions