Emmaus:  For the development of Christian Leaders

Grace Emmaus

 of Silicon Valley

Application Form

TO BE FILLED OUT BY THE APPLICANT:

Name: ________________________________  Address: ______________________________________________

City:  ______________________________________________  State:  _______________Zip:  ________________

Phone:  (________) ___________________________  Emergency Phone: (________) ________________________

Email Address:  ____________________________@______________________________  Your age:  __________

Name you want on your nametag:  _________________________________________________________________

Marital Status:  M___ S___ D___ W___ Sep___      Number of Children: _______  Ages: ______________________

Are you on a special diet? _______   If yes, what: _______________________________________________________

Are you on any special medications? List:  ____________________________________________________________

Do you have health needs or a physical handicap that may affect your attendance at Walk to Emmaus?  ______________

If yes, please specify:  ___________________________________________________________________________

____________________________________________________________________________________________

Education, Degrees, or Training:  ___________________________________________________________________

What is your present occupation:  __________________________________________________________________

Name and phone number of nearest relative not living with you:  ________________________ (____) ____-________

Name and denomination of church now attending:  _____________________________ ________________________

Pastor's Name:  _____________________________________________

In what church activities are you active?  _____________________________________________________________

____________________________________________________________________________________________

Has the Walk to Emmaus been explained to you?  __________

Have activities of the Walk to Emmaus Community been explained to you?  _____________

State briefly why you wish to be involved in the Walk to Emmaus Community and what you expect from it:   __________

____________________________________________________________________________________________

____________________________________________________________________________________________

Signature:  ____________________________________________   Date:  _________________________________

Please fill in all blanks, and return this to your sponsor when it is completed.

 
TO BE FILLED OUT BY THE SPONSOR:

Name: ________________________________  Address: ______________________________________________

City:  ______________________________________________  State:  _______________Zip:  ________________

Phone:  (____) _________________  Work: (____) ___________________Cell: (_____) _____________________

Email Address:  ____________________________@______________________________  Your age:  __________

Name you want on your nametag:  _________________________________________________________________

Do you receive the newsletter? _______     Are you in a reunion group?  ________

Name and denomination of the church you attend:  _____________________________________________________

Do you attend regularly? __________    Where did you make your Walk/Cursillo? ____________ When? __________

How many Pilgrims have you sponsored in the past?  ___________________________________________________

How long have you known this Pilgrim? ___________   Are you praying and sacrificing for your Pilgrim? ____________

Why do you want to sponsor this person?  ___________________________________________________________

____________________________________________________________________________________________

Is this person under any temporary emotional strain or have a physical condition that might indicate his/her weekend 
should be postponed?___________________________________________________________________________

Are you able and willing to assist the Pilgrim to get into an Emmaus Reunion Group? ____________________________

If the Pilgrim is married, have you discussed the Walk to Emmaus with his/her spouse and are in the process of sponsoring

him/her also? _________  If not, why?______________________________________________________________

Date of the Walk for which you wish to register your Pilgrim?  ____________________________________________

Signature of Sponsor(s): ____________________________________________    Date: ______________________

Signature of Sponsor(s): ____________________________________________    Date: ______________________

TO BE FILLED OUT BY CLERGY:

Is the applicant an active member of your congregation?  _________________________________________________

I approve the attendance of the applicant at the Walk to Emmaus Weekend. __________________________________

I would like more information about the Walk to Emmaus ________________________________________________

Please print your name: __________________________________ Church Name:____________________________

City:  ______________________________________________  State:  _______________Zip:  ________________

Signature: ________________________________________   Date:______________________________________

SPONSOR:  Print this page, completely fill it in, obtain signatures, and mail with the registration fee.  
$25 per Pilgrim if received by early registration date or $35 if received later. 
Make checks payable to Grace Emmaus of Silicon Valley.
Electronic registration can be used for temporarily holding a place, but the signatures & check must still be sent.  Instead of using this form, Download an attached Word doc, fill it out, and email it to:  register4emmaus@comcast.net.   Then print out that Word doc. 
Registration is complete only after this form (completely filled-in) and check are received. 
The Grace Emmaus of Silicon Valley website is: http:// www.gracewte.org 
MAIL TO:

Ginny Carlson
 1248 Wasatch Drive
Mountain View , CA 94040