EmailMeForm
SEI Emmaus Pilgrim Application
Please note that any field with an * must be completed.
Walk Attending
*
Men's - 127 Fall 2024
Please select
Spring
Fall
N/A
Women's - 128 Fall 2024
Please select
Spring
Fall
N/A
Name - Please use first and last name as you would like it to appear on your name tag
*
First
MI
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Phone
*
###
-
###
-
####
Please list most accurate number to reach you
Alternate Phone
###
-
###
-
####
Email
*
This is how you will receive any important information from SEI Emmaus Community
Confirm
Date of Birth
*
MM
/
DD
/
YYYY
Occupation (not place of employment)
*
Marital Status
*
Please select
Single
Married
Divorced
Seperated
Widow
If Married, please complete the next section.
If not, please skip and continue.
Spouse Name
First
MI
Last
Have they attended an Emmaus Walk?
If yes, Where & When?
If no, have they applied?
If no, Why?
Church Name & Location
*
Pastor's Name
*
Pastor's Contact Number
*
To help you have a safe and enjoyable Walk to Emmaus, our team will need to know of any special
medical or dietary needs you may have. Please type NONE if there are no special needs
This necessary information will help us accommodate you at the Walk.
Medical Conditions that might limit your participation
*
List any medications you may need during the walk:
*
Please list name and time to be taken.
Special Dietary Needs:
*
*
Are you able to navigate stairs? There are two floors of rooms
Please select
Yes
No
Are you able to reach & sleep on a top bunk?
Please select
Yes
No
Please Note... Bottom Bunks are Limited, causing you to be placed on a waiting list
Emergency Contact Name
*
First
Last
Emergency Contact Relationship
*
Please select
Spouse
Friend
Father
Mother
Son
Daughter
Grandfather
Grandmother
Brother
Sister
Uncle
Aunt
Cousin
Other
Emergency Contact Phone Number
Day
Evening
Other
Sponsor's Name
*
Sponsor's Contact Number
*
Sponsor's Email Address
*
Relationship to Sponsor
*
Please select
Spouse
Friend
Father
Mother
Son
Daughter
Grandfather
Grandmother
Brother
Sister
Uncle
Aunt
Cousin
Other
Has your Sponsor discussed the following with you?
*
$50 non-refundable deposit due with application?
Please select
Yes
No
$90 due at Registration time?
Please select
Yes
No
That the Walk begins Thursday evening and ends Sunday evening?
Please select
Yes
No
The importance of not using Cell Phones, Cameras, or any Social Media while on the Walk?
Please select
Yes
No
Electronic Signature
First
MI
Last
By submitting this application, I affirm the facts set forth in it are true and complete. I understand if I am accepted as a pilgrim, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
Date
MM
/
DD
/
YYYY
