ILLINOIS PRAIRIELANDWALK TO EMMAUS COMMUNITY

Fall Walk #24

 

Weekend Date:  Men’s: Sept 30 – Oct 3, 2010     Women’s: Oct 14 - 17, 2010

 

Will the APPLICANT please print and answer all questions so your needs will be met while you are on the Walk.

 

Male   /   Female   (Circle One)

 

Name: ___________________________________________________________________________________________

 

Address: __________________________________________________________________________________________

 

City: _______________________________________________________     State: _________     Zip Code:__________

 

Telephone: _________/__________/__________   Cell Phone: _________/__________/__________      

 

E-Mail: _________________________________________________________________________________________  

 

Age: ________   Circle Marital Status:     S     M     D     W     Spouse: _________________________________________

 

Name you wish to have on your name badge: ____________________________________________________________

 

Name and denomination of your church: ________________________________________________________________

 

Pastor’s Name: ____________________________________________________________________________________

 

What religious or community organizations are you active in?   ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Has the Walk to Emmaus been explained to you?     YES     /      NO

Has Grouping and Post-Emmaus been explained to you?     YES     /     NO

 

HEALTH INFORMATION

 

I’m on the following diet?    NO     Renal     Cardiac     Diabetic     Other_____________________________

 

I’m allergic to the following foods:  Dairy Products     Wheat     Peanuts     Nuts    Eggs     Soy    Seafood Other_____________________________________________________________________________________________

 

Are you on any special medication that is required to be taken at an exact time?     NO     /     YES, please explain ____________________________________________________________________________________________________________________________________________________________________________________________________

 

Do you have any health or physical handicaps?    NO     /     YES, please explain _________________________________ __________________________________________________________________________________________________

 

Would you be able to sleep on the top bunk?  YES     /     NO

 

Signature: ___________________________________________________________________   Date: _____/_____/_____

Please enclose a pre-registration deposit of $20 with this application.  This will be applied to your contribution of $95 which will partially offset the expenses of your weekend.  This deposit is not refundable.  Balance of $75 is due at registration time.  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 back side of the application and send it in.  Thank you.

This section should be filled out by the Candidate’s SPONSOR who has already attended an Emmaus, Cursillo, Tre Dias, or Chrysalis weekend.

 

Date of weekend: _____/_____/_____           Candidate’s Name: _________________________________________________

 

Sponsor’s Name: ______________________________________________________________________________

 

Address: ______________________________________________________________________________

 

City: _____________________ State: _________     Zip Code: __________           

E-mail: __________________________________________________________

 

Home Phone:_________/_________/__________    Cell Phone:______/________/__________

 

Church you are regularly attending? ____________________________________________________________________

 

What was the name of the walk you attended? ____________________________________________________________

 

When? __________/__________/__________    Are you now in a weekly grouping?   YES /  NO

 

Are you praying and sacrificing for your candidate?   YES   /   NO

 

How long have you know the candidate?  ___________ years.

 

Why do you feel that this person will make a good candidate? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Is the candidate’s Pastor aware that the candidate is making the walk?     YES   /   NO

 

Do you feel that this candidate is capable of making a weekend?    YES   /   NO

 

Are you able to assist the candidate to get into a 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 explained Groupings and Gatherings to the candidate?   YES   /   NO

 

PLEASE RETURN THIS APPLICATION AS SOON AS POSSIBLE TO:

 

Denil Mueller

25833 Joe Knight Road

Dow,Il 62022

Or e-mail to registration@ipwe.org

 

SUBMITTING APPLICATION DOES NOT GUARANTEE ACCEPTANCE

THANKS FOR YOUR TIME AND SUPPORT FOR THE WALK TO EMMAUS

PRE-REGISTRATION DEPOSIT - $20     received _______/_______/_______ check #_____

REGISTRATION BALANCE - $75    received _______/_______/_______ check #___________

PAID IN FULL _____/_____/_____ check#_____________