APPLICATION: Coastal Carolina Emmaus Community
Please print or type (all except Signature) Rev. 3/24/2007
Name:_____________________________________ Sex: ___(M/F) Age: ____ Can you attend on short notice? ___(Y/N)
Name you want on nametag:______________ Street Address:_______________________________________________
City:_________________________________________ State:____ ZIP:__________ Home Phone: (____)__________
Work Phone (& ext): (____)_________________Occupation:______________________________________________________
Email address:_______________________________ Spouse's Name __________________________________
Church Name: ____________________________ Church or Pastor's Address: ________________________________________
*Please list dietary needs (e.g., vegetarian) ______________________________________________________________________
*Please list medicines you take, (other than upon arising or at bedtime), or medical concerns: _________________________________
_____________________________________________________________________________________________________
*Please list any physical limitations: ___________________________________________________________________________
Name, address, and phone
number of nearest relative NOT living with you:
Name: _______________________________________________ Phone
No: (_____)__________________________________
Address _________________________________________________________________________________________________
Has the purpose of the walk been explained to you? ____ (Y/N) Have the follow up activities been explained to you? ____ (Y/N)
Applicant’s Signature: _____________________________________________________________ Date ___________________
Pastor’s Name:________________________________________________ Church Phone:______________________
Please Note: A deposit of $40.00 must accompany this application. Make any checks payable to CCEC (Coastal Carolina Emmaus Community). If assigned a weekend and you fail to attend, the deposit is not refundable. Balance of $85 (check please) is due at the beginning of the weekend. This is only an application to attend a weekend. Notification of your acceptance for a specific weekend will be made by mail about one month after application is received. After completing this application, please return it with check to your sponsor for their completion.
Please verify that applicant has answered “Y” that the “purpose of walk” and “follow up activities” have been explained. If applicant has a
spouse who has not walked, discuss with spouse the possibility of spouse’s walk also. Confirm these items and verify you are prepared to
fulfill sponsor responsibilities listed below: _______ (Y/N)
-Avoid serving in the conference room on your pilgrim’s walk
-Transport pilgrim to and from walk, take to dinner as you can before and after walk (your Agape)
-Cover pilgrim’s home needs during walk
-Check pilgrim in for “Sendoff”/“Sponsor’s hour”, sign up for prayer vigil, attend special events, attend “Closing”
-Follow up with pilgrim after the walk: follow up meeting, reunion group, Gatherings
Sponsor’s Name:_________________________________________________ Sponsor’s Phone No.(_____)___________________
Alternate phone number(_____)____________ Email address:________________________________________________________
Home Address:______________________________________________________________________________________________
City:________________________________________________________________ State:_______ ZIP:_________
Name of Church you attend:_________________________________ Where, when was your walk? __________________________
Sponsor’s signature:____________________________________________________________ Date:_________________________
Verify form is complete, $40.00 deposit is enclosed, & mail to: Coastal Carolina Emmaus, PO Box 4826, Wilmington, NC 28406