Southern Ohio Emmaus - Application

1 Southern ohio Emmaus - Application This Application is to be f illed out b y the Candidate. Kindly f ill i n all the areas t hat apply to you. All of th e information you s upply is f or appropriate placement o n the walk and will s tay c onfidential Request f or Reservation for following walk, p lease check one: TO B E COMPLETED BY T HE APPLICANT ( PLEASE PRINT): Name Preferred f irst n ame for nametag Address Email A ddress City State Zip code Home Phone Work P hone Marital Status Sex M F Age Employer Spouse Name Occupation Has your spouse been o n a Walk? No Yes If s o, Walk Number Church you attend Pastor LIABILITY R ELEASE: By s igning t his f orm, I understand t hat I release the Southern O hio Emmaus Community, , Camp Akita, T he Upper R oom and any other party directly or indirectly i nvolved with any Emmaus Walk from any and all liability, c laims, o r demands for personal injury, as well as personal property d amage or any expenses as a result o f participation in the Emmaus Walk.

2 PARTICIPANT S SIGNATURE Date Southern ohio Emmaus intends to use information above this line to update our Membership Database All information below this line w ill be destroyed when no longer needed for this Emmaus Walk Are you on a special diet? No Yes Explain Are you on any medication? No Yes Explain Do you have any medical o r physical limitations that may affect your participation at the Emmaus Weekend? No Yes Explain In case of emergency d uring t he weekend, contact: Daytime Phone Evening Phone Has th e Emmaus Walk been explained to you? Briefly, why do you wish to attend the Emmaus w eekend and what do you expect to get f rom i t? Close f riend s n ame: Friend s ad dress an d phone# Please attach a non-refundable pre-registration deposit o f $ This d eposit will be applied toward t he contribution of $ This partially offsets th e expense of the Emmaus w eekend.

3 Make Checks payable to: Southern O hio Emmaus Registrar Amy Finck 549 Logan Street Junction City, OH 43748 614-364-5956 Registrar Email Men's Spring #66 March 14 - 17, 2019 Women's Fall #67 September 5 - 8, 2019 Men's Spring #68 March 12 - 15, 2020 Women's Fall #69 September 10 - 13, 2020 Women's Spring #66 April 11 - 14, 2019 Men's Fall #67 Oct 31 - Nov 3, 2019 Women's Spring #68 April 16 - 19, 2020 Men's Fall #69 October 8 - 11, 2020 Revised March 2019 Sponsors please complete Application and submit to Registrar SPONSOR S I NFORMATION (to be c ompleted by Sponsor) Pilgrim s Nam e: TO B E COMPLETED BY T HE SPONSOR (PLEASE PRINT): Sponsor s Nam e Address Email A ddress City State Zip code Home Phone Work P hone What walk di d you attend? Emmaus Community: Walk Number: If not c urrently affiliated with Southern ohio Emmaus , which community?

4 Church you attend Pastor Have you ever sponsored someone? No Yes Have you attended a s ponsorship class? No Yes If you have not attended a sponsorship c lass, you must h ave a c o-sponsor who has at tended a s ponsorship class. Co-Sponsor Name (If r equired) Address Email A ddress City State Zip code Home Phone Work P hone PLEASE ANSWER THE F OLLOWING Q UESTIONS Have you explained t he Walk to E mmaus to your pilgrim? Yes No Does your pilgrim have any s pecial needs we s hould know a bout? _Yes No If s o, what are th ey? Have you explained t he $ fee to your pilgrim? Yes No Do you, as a sponsor, understand t hat the registration f ee i s t o be paid prior t o attending t he walk?

5 Yes No Will you be bringing your pilgrim to Camp Akita on T hursday night? Yes No If not, who will? Phone # Do you understand that i t is your r esponsibility t o a ttend t o any ne eds your pilgrim s f amily m ay have while your pilgrim i s on t he walk? Yes No Will you be attending closing on Sunday in order to gi ve your pilgrim a way home? Yes No If not, have you made arrangements f or your pilgrim to get home? Yes No Will you be available t hroughout the weekend in case of e mergency? Yes No If not, who will? Phone # If you h ave a ny questions, you s hould get in t ouch with t he r egistrar t hat is i n c harge of your pi lgrim s w alk. B oth nu mbers are on the bottom of th e Emmaus A pplication Form. Revised:If needed, you can contact the Chairperson:Randy Dudding 740-590-3031 March 2019