Illinois Prairieland Walk to Emmaus
Spring Walk #26
Men’s
Weekend: April 19-22, 2012 Women’s Weekend: April 26-29, 2012
This section to be completed by the APPLICANT. Please print the answer to all questions so that your needs can be best met
during your Walk to Emmaus.
Male / Female (Circle One)
Name:____________________________________________________________
Address:
______________________________________
______________________________________
______________________________________
Primary
Telephone : (____)_____-_______ Cell Phone: (____)_____-_______
E-Mail:
______________________________ Age:
________
Circle
Marital Status: S M D W Spouse’s Name _______________________
Name
you wish to have on your name badge: ____________________________
Sponsor’s
Name: ____________________________
Name
and denomination of church where you are an active member:
_____________________________________________________________
Pastor’s
Name: ____________________________
What
ministries are you active in at your church?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What
community organizations are you active in?
____________________________________________________________________________________________________________________________________________________________
Has
the Walk to Emmaus been explained to your satisfaction? YES
/ NO
Have
Grouping and Post-Emmaus been explained to you? YES / NO
Are
you on a special diet? NO Renal Cardiac
Diabetic
Other
Please
explain: ______________________________________________________
Are
you allergic to any foods? NO Dairy Wheat Peanuts
Nuts Eggs Soy Seafood Other
Please
explain: ________________________________________________________________
Please
list any special medications that you are currently taken and the times they
must be taken:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do
you have any physical or mental challenges? NO / YES, please explain:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Would
you be able to sleep on a top bunk? YES / NO / YES,
BUT PREFER NOT
Sign:
____________________________________ Date:
______________
Please
enclose a pre-registration deposit of $20 with this application. This will be
applied to your total registration of $95. This deposit is non-refundable. The
remaining balance of $75 is due at your weekend registration. Please make
checks payable to ILLINOIS PRAIRIELAND
WALK TO EMMAUS or IPWE. After
completing this application, give it to your sponsor ASAP, who will fill out the remaining portions and send it in. Thank you.
**Applications received by 9/9/2010,
with $20 deposit, will receive an additional $20 credited to their balance.
If you feel that you are unable to meet
the financial demands of attending a Walk to Emmaus Weekend, there are some
scholarships available. Please indicate with an x in the space below if you
need to request scholarship assistance.
______ I am in need of a full scholarship of
$95
______ I am in need of a half scholarship of
$48
SUBMITTING APPLICATION DOES NOT GUARANTEE ACCEPTANCE
PRE-REGISTRATION DEPOSIT - $20 received _______/_______/_______ check
#________
REGISTRATION BALANCE - $75 received _______/_______/_______ check
#___________
PAID IN FULL _____/_____/_____ check#_____________
This section
should be filled out by the Candidate’s SPONSOR who has already attended an
Emmaus, Cursillo, Tres Dias,
Journey, or Chrysalis weekend.
Candidate’s
Name: _______________________________________________
Sponsor’s
Name: _________________________________________________
Sponsor’s
Address: ______________________________________
______________________________________
______________________________________
Primary
Telephone : (____)_____-_______
Cell
Phone: (____)_____-_______
E-Mail:
______________________________
Church
you are regularly attending: _______________________________
Name
of Walk You Attended (Community/Walk #/ Year, if known):
______________________________________________________
Are
you now in a reunion group? Yes / No
Are
you praying and sacrificing for your candidate? Yes / No
Is
the candidate's pastor aware that he/she is making a walk? Yes / No
Are
you able to assist the candidate to get into weekly grouping? Yes / No
If
the candidate is married, have you explained Emmaus to the spouse? Yes / No
Will
you care for the spouse over the weekend? Yes / No
Will
you bring the candidate to the weekend site? Yes / No
Will
you participate in the weekend? Yes / No
Have
you read the Sponsorship Tips document available online? Yes / No
How
long have you known this candidate? _____ years.
Briefly
explain why you think this person would make a good candidate:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please tell us more about your candidate.
Circle the most appropriate response and provide an explanation as necessary.
Is your candidate more...?
Extroverted / Introverted
Sensing /
Intuitive
Thinking (Analytical) / Feeling (Emotional)
Sequential / Global
Leader / Follower
Impressionable / Decisive
Joiner / Observer
Please share any concerns or anything
else that you feel would be helpful to the team:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PLEASE RETURN THIS APPLICATION AS SOON AS POSSIBLE TO:
Sharon
Coyne
699
Boulevard de Cannes
Edwardsville,
IL 62025
Or
e-mail to registration@ipwe.org