Pilgrim Application – Cincinnati Emmaus Community

Section 1: Participant's Information

Name (as you wish it to appear on nametag)

First Last

Gender

Birth Date

Address

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

Email

Phone

Spouse/Family Member Name

First Last

Spouse/Family Member Phone

Has your spouse, parent, or child attended an Emmaus Walk, Face To Face Encounter or Chrysalis Flight? If so, please give the date attended, location, and walk/encounter/flight number:

Sponsor's Information

Sponsor's Name

First Last

Sponsor's Email

Sponsor's Phone

Name of Close Friend

First Last

Friend's Phone Number

Friend's Address*

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

Friend's Email

Name of Church You Attend

Church Phone Number

Pastor's Name

First Last

Pastor's Email

Has the Walk to Emmaus been explained to you?*

Have Sharing Groups and Monthly Gatherings been explained to you?*

Please share briefly why you want to attend the Walk to Emmaus*

Section 2: Participant's Special Needs & Medical Information

The purpose of sections 2 and 3 are to provide medical information in the unlikely event that medical treatment is necessary during an Emmaus Walk. All information will remain confidential.

Emergency Contact Name

First Last

Relationship to participant

Emergency Contact Phone Number

Emergency Contact Address

Street Address City State ZIP Code

Primary Care Physician's Name

First Last

Physician's Phone Number

Preferred Hospital

Hospital Phone Number

Are you allergic to any medications?

Will you bring any medication (prescription or over the counter) to the Emmaus Walk? If so, please bring a list that contains each medication, along with dosage and frequency.

Do you have any dietary restrictions or concerns? If so, please explain:

Do you have any allergies (i.e. bees, idoine, nuts, etc.)? If so, please explain:

Do you have any mobility concerns (need assistance, trouble with stairs, etc.)? If so, please explain:

Do you have any sleeping concerns (apnea, C-PAP, heaving snoring)? If so, please explain:

Is there any additional information regarding your special needs, and medical health that you feel the team should know about?*

Section 3: Authorization for Medical Treatment

In the unlikely event that medical intervention is necessary for the Participant, every attempt will be made to contact the individual designated as “Emergency Contact Person.” Only if that person cannot be reached in an emergency during the Emmaus Walk for which permission has been granted for the Participant to participate, I hereby give my permission to the Emmaus Leadership Team to hospitalize at preferred hospital (or any hospital reasonably accessible),secure medical treatment and order any injection, anesthesia or surgery for myself as deemed necessary. I understand that I am liable for any expenses incurred due to emergency treatment. I understand all reasonable safety precautions will be taken at all times by the Greater Cincinnati Emmaus Community and its agents during the Walk sponsored by same. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Greater Cincinnati Emmaus Community, its Board of Directors, its leaders, employees or volunteer staff liable for damages, losses, diseases or injuries by the subject of this form.

Digital Signature (please type) of parent or participant if participant is 18 or older:*

First Last

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