Face to Face Application – Cincinnati Emmaus Community

Face To Face Registration

Fees

Return completed application with deposit of $30 and balance of $30 due prior or first day of Encounter.

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Email

Phone

Your Church Affiliation*

Previous Occupation

Year of Retirement

Pastor's Information

Pastor's Name

First Last

Church Name and Address

Street Address City State ZIP Code

Pastor's Phone Number

Pastor's Email

Friend's Information

Friend's Name

First Last

Friend's Address*

Street Address City State ZIP Code

Friend's Phone Number*

Friend's Email*

Family Information

Family Name

First Last

Address

Street Address City State ZIP Code

Family Phone Number

Family Email

Sponsor's Information

Sponsor's Name

First Last

Sponsor's Address*

Street Address City State ZIP Code

Sponsor's Email

Sponsor's Phone

Emergency Contact

Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Primary Care Physician & Phone Number

Name

Phone

Dietary Restrictions or Concerns

Mobility Concerns (needs assistance, trouble with stairs, etc.

Other Concerns We Need To Know

Fees

Return completed application with deposit of $30 to be applied to the total cost of $60 due prior or first day of Encounter. Contact your sponsor for details. Or go to the Event Info menu and choose participant fees to pay online.