Pilgrim Application Please fill out the following to the best of your ability. Step 1 of 3 33% Personal InfoFull Name* First Last Name you prefer to be called Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Phone*Email* Enter Email Confirm Email Gender* Male Female Birthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation* Marital Status* Single Married Separated Divorced Spouse's First Name* Has your spouse attended a Walk to Emmaus or submitted an application to attend?* Yes No Do you have any physical condition (including diet) that may affect your attendance?* Yes No If YES, please specify any dietary restrictions and/or medication so that we can accommodate your needs during your Walk. This information will be kept confidential and will not prevent you from attending a Walk.* Church AffiliationSponsor Name* Sponsor Phone*Sponsor Email* Enter Email Confirm Email Home Church Name* Denomination* Church Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Church Phone*Pastor's Name First Last Church work / committees you are involved in:* Additional InfoPlease state briefly why you want to attend an Emmaus weekend, what you expect from the experience, and any other information about yourself or your faith you wish to share:*NOTE: This is an application expressing your desire to participate in a Walk to Emmaus event. You will re- ceive notification of your acceptance for a weekend approximately one month beforehand; however, we cannot guarantee acceptance for a particular Walk. A $50.00 non-refundable application fee, made payable to “Richmond Emmaus,” is required. THERE ARE NO ADDITIONAL COSTS TO YOU FOR THE WEEKEND. After completing this application, give it to your sponsor to complete Page 2 of this form, and include your $50 application fee. If you have questions, please contact your sponsor.Agreement* I AGREE Δ
