Online Application

Welcome to our Online Pilgrim Apllication. Make sure you fill out this application completely. After you complete this application you will receive a confirmation email. If for some reason you do not please EMAIL US to keep us imformed.

You can also pay your $40 deposit fee by going to our Donate page and pay via PayPal or credit card. This is a fast secure method for your convenience.

REMEMBER: This Online Application is NOT required, it is just an additional tool you CAN use if you would like to. You can still download a paper form and mail to us as you have in the past.

Pilgrim Basic Info

First Name * Last Name * Name on Tag * Gender Male Female * Birth Date Clergy * Street Address * City * State * Zip Code * Home Number * Work Number Cell Number E-mail Address * Occupation * Marital Status * Has your spouse attended Emmaus * Is spouse attending Adjacent Walk? *

Medical and Health

Do you require physical assistance? If so, please explain

Do you take medications during the day? List the Schedule

Please specify any dietary needs you require us to provide

Are you a vegetarian? *

Allergies Do you have any medication or environmental allergies that we need to be aware of?

Misc Info

This information is important in case of an emergency!

Name of Emergency Contact (Other than spouse) * Telephone & Relationship * Church Name * Church Address Pastor Church's Phone *

Community Info

Has the purpose of the walk been explained to you? * Have the follow up activities been explained to you? * Can you attend on short notice? *

Sponsors Section

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone *

Cell Number

Email *

Sponsors Walk No. *

Sponsors Walk Community *

Date of Sponsor Training *

Please enter the as shown (Case Sensitive)

Thank you for submitting an Online Application. The community registrar will be in contact with you real soon.

The deposit for this application is $40. You can pay online via PayPal or you can mail a check to:

Coastal Carolina Emmaus Community
PO Box 4826
Wilmington, NC 28406