Pilgrim Registration Women's Walk 191

Name

This address will receive a confirmation email

Phone

Address

What name would you like on your name tag?

What is the name of your home church?

What is your pastor's name?

Are you married?

YES NO

If applicable is your spouse registering to take the Walk to Emmaus? YES NO

Emergency Contact Information

Name of Emergency Contact:

Relationship of Emergency Contact:

Emergency Contact Phone Number:

Medical Information

Name of your Doctor:

Doctor's Phone Number:

Name of your Insurance Company:

Insurance Policy Number:

I authorize release of my medical information for emergency purposes.

YES NO

Personal Needs

List any physical limitations you may have.

List any dietary requirements:

General sleeping conditions provided include a sheet covered twin mattress on the floor of a classroom. A limited number of cots are available upon request.

Do you need a cot for sleeping?

YES NO

Will your sleeping area require electricity?

YES NO

Sponsor Information

Sponsor's Name:

Sponsor's Email Address:

Sponsor's Phone Number:

Sponsor's Address

If 'other' was selected on the previous question please list details on Sponsor's original walk here:

The Walk to Emmaus is intended to be a leadership training/educaitonal event offered to believers looking for a deeper walk with Christ. It is not to be used as an introduction to Christianity or as an emotional healing/therapy weekend.

Do you feel the pilgrim is ready for the Walk to Emmaus

YES NO

Is the pilgrim a member of the clergy?

YES NO

Have you informed the pilgrim's pastor about your pilgrim attending the Walk to Emmaus?

YES NO

If your pilgrim is married have you shared information about the Walk to Emmaus with their spouse?

YES NO

Can you care for the needs of your pilgrim's spouse and/or family over the weekend?

YES NO

Have you explained to your pilgrim that outside contact during the weekend is 'emergency' only?

YES NO

Payment

Emmaus of Southeast Michigan utalizes PayPal. You will be directed to a PayPal page and then returned to this form to click submit once you have completed your payment.

Scholarships are available upon request by contacting the Emmaus of Southeast Michigan Treasurer at treasurer@emsem.org. Select the payment option of $0 for scholarship requests.

If paying by check, please mail to:

Emmaus of SE MI
Bryon Weise

29051 Cambridge

Flat Rock, MI 48134

Payment

Pilgrim Registration Women's Walk 191

Description

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