Husband and wife applications should be submitted at the same time.  Any exceptions will be at the discretion of the Spiritual Director and Executive Committee. Deposit Received:______________________________________ Mail to: CIE Registrar Carolyn Turner 1194 E. 1330th St. Quincy, IL  62305

                    

TO BE COMPLETED BY CANDIDATE:

Current Date:______________________________ Walk Date Preferred:___________________________

Name:___________________________________  Address:____________________________________

Phone:______________ City:_______________________ State:___________ Zip Code:_____________

Name preferred on tag:________________________________________

Your Age:___________ If married, spouse’s name: __________________ Number of Children _________

Single:             Divorced:               Widowed:               Separated:        

Occupation:___________________________________

Employer’s Name:_______________________________ Business Phone: _________________________

How many years of formal education have you had? _____________________

Denomination now attending:_________________________ Pastor’s Name:________________________

In what religious or community organizations are you active? _____________________________________

Has the Walk to Emmaus been explained to you?             Yes   No

Have weekly reunions and other Emmaus follow-up meetings been explained?               Yes          No

Are you on a special diet?         Yes          No   If so, what?______________________________________

Special medication?            Yes            No   If so, what?__________________________________________

Do you have a health problem or physical handicap which may affect participation on an Emmaus weekend?          Yes          No   If yes, please specify:__________________________________________ _____________________________________________________________________________________

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

__________________________________________________________________________________________________________________________________________________________________________

Candidate Signature: __________________________________________

All of the above information is necessary for your proper placement in a Walk to Emmaus.  Please fill in all the blanks.  Please enclose a pre-registration deposit of $25.00.  This will be applied to your contribution of $150.00 which partially offsets the expenses of the weekend.  This deposit is not refundable.  Make your check payable to:  Great River Emmaus Gathering Community

THIS FORM WILL BE HELD IN STRICT CONFIDENTIALITY.