Kickapoo Canoeing & Wildcat Camping Trip

(Print this page, fill it out and return it to Pastor Leistekow)

Immanuel Ev. Lutheran Church

Permission & Registration Form

Event:   Kickapoo Canoeing & Wildcat Mt. Campout              Date:         June 20-21, 2017  

Participant’s Name:                                                                                                   Phone #                              

Parent/Guardian Name:                                                                                           Phone #                              

Other Emergency Contact #’s                                                                                                                       

Does your child have any allergies, medical conditions or dietary restrictions we need to be aware of?

YES                                     NO

If “Yes” please list:                                                                                                                                            



Year of last tetanus shot:                                                                                                                                


In case of an emergency, is there anything we need to know about your child?


Permission Statement

  • I give permission for my child to attend the above function or activity with Immanuel Ev. Lutheran Church.
  • I give my consent to the representatives of Immanuel Ev. Lutheran Church to provide basic first aid to my child if needed and to make the necessary decisions for transportation to and/or treatment at a hospital or urgent care facility and for a licensed healthcare professional to administer any emergency care my child may need. Parents/Guardians will be informed as soon as possible in case of any emergency or medical treatment. In the event that parent/guardian cannot be reached, an Immanuel Ev. Lutheran Church staff member will use their best judgment in authorizing any medical treatment/action.


Parents’ Signature:                                                                                               Date:                                    


Circle items you can provide if needed:            Canoe            Tent            Transportation


Please return this completed form to Pastor Leistekow by June 18.