Applicant's Name:_____________________________________Name for Name Tag:____________
Mailing Address:________________________________________________________________
City/State/Zip:__________________________________E-Mail:_______________
Home Phone: ( ____ ) _________________Cell/Work/Business
Phone: ( ____ ) ___________
Age:__________ Gender:____________
Birthday:_________________________
Circle Current Marital Status: | Married | Single | Separated | Divorced | Widowed | ______# years
Spouse's Name:_________________Has
Spouse attended The Walk to Emmaus®?_________
Number of Children:_______ Name(s) & Ages(s) of Children living with you:
__________________________________________________________________________________
Emergency contact name, address &
phone number of family member not residing at home:
__________________________________________________________________________________
Name, denomination &
location of the Christian church you currently attend:
__________________________________________________________________________________
Name & Phone # of Pastor:_________________________________________________________
Current Religious & Community
Activities:_________________________________________
__________________________________________________________________________________
Occupation:_____________________ Former Occupation if Retired:_________
Please Circle Appropriate
Answer Below:
| Yes | No | Has your Sponsor explained the Walk to Emmaus® experience to you?
| Yes | No | Has the Walk to Emmaus® Follow-Up & Reunion Group been explained to you?
| Yes | No | Have you read the information on our website at www.gbgm-umc.org/mountaintop?
| Yes | No | Do you have
any limitation that might affect your full participation?
| Yes | No | Can you climb
stairs?
| Yes | No | Can you sleep
in a top bunk?
| Yes | No | Are you taking
medication? If yes, specify:_________________________________
| Yes | No | Do you require a
physician prescribed diet? If yes, specify (normal meal served otherwise):
_________________________________________________________________________________
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:__________________________________________________________________ |
