Name:  __________________________________________________________

Address: _____________________________________ Phone: ____________

City: ____________________________ State: ____ Zip: ________________

Married: ____ Single: ____ Divorced: ____ Widowed: ____ Separated: ____

Spouse' Name _____________________

My Spouse attended Emmaus Walk # ____ at ________________

Your Present occupation ____________________ Your age __________ # of children _______

Company name ________________________________ Business Phone: (      ) _____________

Name of a close, personal friend __________________________________________________

Address : ______________________________________ Phone: (      ) ____________

Do you have a health problem or disability that may affect your attendance at an Emmaus Walk? _____

If yes, please specify:

Are you on medications or a special diet? ____ If yes, specify: ________________________________

Name and denomination of the church you are now attending: ______________________

Address of Church: _______________________________________________________________

Minister's Name: __________________________

In what church/religious organizations are you active?

____________________________________________________________________________________

Has Emmaus been explained to you ? __________________

State briefly why you wish to attend an Emmaus weekend and what you expect from the experience:

____________________________________________________________________________________

____________________________________________________________________________________

If there were a last minute cancellation, would you be able to come for an Emmaus weekend with short notice? _____Yes _____ No

Signature: ________________________________

SPONSORSHIP INFORMATION

Sponsor's Name: ______________________________________________

Sponsor's Address: ________________________________________________

Phone: (      ) ___________

Sponsor's City: ______________________________ State: ____  Zip: ______________

Community and Number of your Walk or Flight: ____________________________________________

Sponsor's Signature: _________________________________

All the above information is confidential and is necessary for your proper placement on an Emmaus Weekend.

Please enclose a pre-registration deposit of $25.00.

This will be applied toward your contribution of $75.00 which partially offsets the expense of the three days.

This deposit is not refundable. Make the checks payable to Wilmington Area Emmaus Community.