Pilgrim Registration

Walk Selection I am applying for: Men's Walk Women's Walk

Personal Information First Name:    Last Name:

Birthdate (xx/xx/xxxx):    Age:

Address:

City: State: Zip Code:

Marital Status:    Sex:

Spouse's Name:    Preferred Name:

Primary Phone:    Secondary Phone:

Email:

Contact Preference (Email or Regular Mail):

Emergency Contact Name: Phone: Relationship:

Health Information Special Diet: Specify:

Diabetic: Vegetarian: Allergies:

CPAP/BiPAP: Smoke: On Medication:

Physical Challenges: Specify:

Sponsor Information Sponsor Name: Sponsor Cell:

Sponsor Email: Are you clergy?

Sponsor discussed: Walk Site Transportation Clothing Bedding Gatherings Reunion Groups

Church & Testimonial Why do you wish to attend:

Involvement in organizations:

Church: Denomination:

Pastor Name: Pastor Cell: Pastor Email:

Final Confirmation

The above information is necessary for proper placement in a Walk to Emmaus. Submission does not guarantee attendance. Cost: $200. A $25 non-refundable deposit is required. Mail checks to:
Sharon Gallagher, Registrar, 101 Dominic Dr Butler, PA 16001
Or pay online after submitting. Email TRWEregistrar@yahoo.com for questions.

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