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.
Women's Spring Walk #73 March 12-15, 2026Women's Fall Walk #74 September 17-20, 2026Men's Fall Walk #74 October 15-18, 2026
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:
NoYes
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:
Yes (Please fill out sponsor's information below)No, I will need a sponsor
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:*

Clear
DATE:*

MonthDayYear
Date
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: Suzette Wallace 284 W Lake St. Roseville, OH 43777

Phone number: 740-603-1191 Email: suznlfd@gmail.com
Revised 01/21/2026
Should be Empty:

Southern Ohio Emmaus - Pilgrim Application

TO BE COMPLETED BY APPLICANT (Please print)