Southern Ohio Emmaus - Pilgrim Application

Southern Ohio Emmaus - Pilgrim Application

souhternohioemmaus.org
This application is to be filled out by the candidate. Kindly fill in all the areas that apply to you. All of the information you supply is for appropriate placement on the walk and will stay confidential.
Request for reservation for following walk, please check one:
TO BE COMPLETED BY APPLICANT (Please print)
Full Name:

First NameLast Name
Preferred first name for name tag:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Cell phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Sex: Male or Female
Age:
Marital Status:
If married, your spouse's name:
Has your spouse been on a walk?
If yes, walk number:
Are you currently Employed?
Choose one option
If your answer was yes or retired, who is/was your Employer:
If no previous employer just put: None
T- Shirt size:
Church you attend
Pastor
Are you on a special diet?
If Yes, please explain:
Do you have any physical limitations?
If Yes, please explain:
There will be mobility devices available if needed.
In case of emergency during the weekend, contact:
Daytime phone:
Format: (000) 000-0000.
Evening Phone:
Format: (000) 000-0000.
Has the Emmaus Walk been explained to you?
Please give a brief statement as to why you wish to attend the Emmaus Walk and what you expect to receive from it?
Close friend's name:
Friend's address and phone number:
Do you have a Sponsor for this walk?
Please provide your Sponsor's Name:
Sponsor's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
LIABILITY RELEASE: By signing this form, I understand that I release the Southern Ohio Emmaus Community, Camp Echo, The Upper Room and any other party directly or indirectly involved with any Emmaus Walk from any and all liability, claims, or demands for personal injury, as well as personal property damage or any expenses as a result of participation in the Emmaus Walk.
PARTICIPANT SIGNATURE:
DATE:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please send a non-refundable pre-registration deposit of $50. This deposit will be applied toward the registration fees of $165.

Make checks payable to: Southern Ohio Emmaus (Please add walk date in memo of check) If your church is paying your fee, please make sure your name is on the check mailed in.

Please mail to Registrar: Cheryl Needs 14821 Cohagen Road Logan, Ohio 43138

Phone number: 740-603-4839 Email: registrar@southernohioemmaus.org

Or Pay Online at our website https://southernohioemmaus.org/pay-online
Revised 01/21/2026
Should be Empty:

Southern Ohio Emmaus - Pilgrim Application

TO BE COMPLETED BY APPLICANT (Please print)