Applicant's Name:_____________________________________Name for nametag:____________
Mailing Address:________________________________________________________________
City/State/Zip:__________________________________E-Mail:_______________
Home Phone: ( ____ ) _________________Work/Business
Phone: ( ____ ) ___________
Age:_____________ Gender:__________________
Birthday:_________________________
Marital Status: _____Married
_____Single _____Separated _____Divorced ____Widowed
Spouse's Name:_________________Has
Spouse attended The Walk to Emmaus®?_________
Number of Children:_______
Name(s) & Ages(s) of
Children:
Provide name, address &
phone number of a family member not residing in your home:
__________________________________________________________________________________
Name, denomination &
location of the Christian church you currently attend:
__________________________________________________________________________________
Name & Phone # of Pastor:_________________________________________________________
Current Religious & Community
Activities:_________________________________________
__________________________________________________________________________________
Current/Retired Occupation:_______________________________________________________
Please Circle Appropriate
Answer Below:
| Yes | No | Has the Walk
to Emmaus® experience been explained to you?
| Yes | No | Has the Follow-Up
Program of the Walk to Emmaus® been explained to you?
| Yes | No | Can you climb
stairs?
| Yes | No | Can you sleep
in a top bunk?
| Yes | No | Do you have
a handicap that might affect your participation?
| Yes | No | Are you taking
medication? If yes, specify:_________________________
| Yes | No | Do you require a
physician required diet? Specify:_________________________
_________________________________________________________________________________
Please list people who know
you who have attended the Walk to Emmaus®:
_________________________________________________________________________________
Why do you feel called to
participate in the Walk to Emmaus®?____________________
_________________________________________________________________________________
What do you hope to gain
by participating?_______________________________________
_________________________________________________________________________________
Your Signature:_____________________________________Date:_____________________
Date of Walk you are applying
for:_______________________________________________
Sponsor's Name:__________________________________________________________________ |
