GREAT PLAINS EMMAUS

Application

Walk Number: ___________________ Date: ___________________

TO BE FILLED OUT BY THE CANDIDATE: (Please provide all the information requested)

Name: Address:

City: State: Zip: Home Phone: ( )

Age: Date of Birth: / / Male: Female: Marital Status ( ) Married

( ) Single

Spouse’s Name: Number of Children ( ) Divorced

Your Occupation: Employer:

E-mail Address: Work Phone: ( )

Name of Church You Attend: Denomination:

Pastor’s Name: Highest Education Level: ( ) High School

( ) College

E-mail Address: ( ) Grad School

( ) Other

Name you would like on name tag:

Can you be off for the entire weekend (Thursday evening through Sunday evening)? ( ) Yes ( ) No

Do you snore? (Check one): ( ) Not at all ( ) Softly ( ) Medium ( ) Loudly ( ) Buildings shake

Do you require any of the following:

· special bedding? Specify:

· special diet? Specify:

· special medications? Specify:

Is there a health problem or physical handicap that may affect your attendance at the Walk? If so, please explain:

Doctor”s Name: Phone: ( )

State briefly why you wish to be involved in the Emmaus Community and what you expect from it:

Have the following been explained to both you and your spouse:

· What the Walk is about? ( ) Yes ( ) No l Post Emmaus Meeting? ( ) Yes ( ) No

· Activities during the weekend? ( ) Yes ( ) No l Monthly Gatherings? ( ) Yes ( ) No

· Reunion Groups ( ) Yes ( ) No l Answer any other questions? ( ) Yes ( ) No

· Transportation to the site? ( ) Yes ( ) No

Is your spouse (if applicable) committed to attending an Emmaus Walk as well? ( ) Yes ( ) No

By signing this form, you will be committing yourself to be present for the entire Emmaus Walk (Thursday evening through Sunday evening).

Candidate’s Signature: Date:

A pre-registration deposit of $25.00 is required. This will be applied toward your total cost of $125.00. This deposit is non-refundable. Please make checks payable to GREAT PLAINS EMMAUS.

For Office Use Only

Paid Deposit: Date: Sponsor: Walk No..: Candidate letter:

Sponsor letter: Spouse attending: Special Needs:

Form: GPEAPPL.DOC Revision Date: 1/06/2003