Greater Dayton Emmaus Pilgrim Application Form
Personal Information
Name
*
First Name
Last Name
Name as preferred on name tag (if different)
Last Name
First Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Age
Gender
Please Select
Female
Male
Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code
Occupation
Occupation
Work phone
Current Home Church
*
Church Pastor's Name
Do you attend regularly?
Other ways you participate at church
Briefly state why you want to attend Emmaus and what you expect
*
Close friend/emergency contact information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code
Email
*
Phone
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Please include a NON-REFUNDABLE pre-registration deposit of $25.00 (Please make check payable to Greater Dayton Emmaus) which will be applied toward your $125.00 charge for the weekend, and return this form to your sponsor. Please send a separate check for each registration.
Your sponsor will complete the reverse side and forward it to the proper registrar.
You may also pay online at: https://daytonemmaus.org/giving.
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