Emmaus Walk Pilgrim Application -

Full Name (First, Middle, Last)

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Phone Number

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Email

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Address

Address Line 1

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Address Line 2

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City

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State

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Postal Code

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Country

Birthday (mm/dd/yyyy)

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Gender

Male

Female

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Occupation (If retired, what was your occupation?)

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Name for Name Tag (First and Last Name)

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Are you a member of the Clergy?

Yes

No

Are you a Musician (sing or play instrument?)

Yes

No

If yes, what instrument?

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Sponsor Name

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Sponsor's Phone Number

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Pilgram's Church

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Pastor Name

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Church Phone Number

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Church Email

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Church Address

Address Line 1

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Address Line 2

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City

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State

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Postal Code

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Country

Emergency Contact Name (other than your Sponsor)

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Relationship

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Emergency Contact Phone Number

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Emergency Contact Address

City

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State

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Please note any significant Health Conditions we should be aware of in an emergency, even if they are currently well managed.

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Do you have Physical Limitations that we should be aware of? If yes, please describe so we can try to accommodate your needs.<br>Ex: do you use a walker, wheel chair, need a handicap shower, are unable to climb stairs, hearing or vision problems

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As you will not be wearing a watch, do you need to take a medication at a time other than with meals, waking, or going to bed? If so, what times?

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Do you have any food allergies or required dietary restrictions? (Peanut allergy, Dairy, Eggs, etc.) If so, note specifics below so we can better serve you.

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Has the purpose of the Walk been explained to you?

Yes

No

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Has your sponsor discussed follow-up activities?

Yes

No

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Can you attend the Walk on short notice if you are placed on a wait list?

Yes

No

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I understand and agree with the statement below:<br><br>A deposit of $75 is required with your application, and the balance must be paid at Registration, if not before. If you are unable to attend the Weekend that you are applying for, your deposit will be rolled over to the next available Walk date. The current cost for the Walk to Emmaus is $225. The cost for the Walk to Emmaus is not guaranteed beyond the current year.

Yes

No

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Additional Comments/Questions

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Pilgrim Application

Medical Information