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First Name:
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Last Name
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Address Street
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City
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State
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Zip
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Home Phone
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Work Phone
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Cell Phone
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Age
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Occupation
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E-mail Address
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Spouse Name
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Has Your Spouse Attended A Walk?
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Your Church
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Your Pastor
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Sponsor's Name
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Sponsor's Phone Number
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Contact Number
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Emergency Contact Name ?
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Please Answer All That Apply To You Below
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Special Medication
Regime ?
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Medical Or
Physical Needs ?
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Special Health Related
Dietary Needs?
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Please Explain All Items Marked YES Above
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Have You Had Any Traumatic Events Within The Last Year Such As The
Death of A Loved One, A Divorce, Loss of Home, Loss of Job, etc?
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Briefly explain in the space below why you have decided to participate in the "Walk To Emmaus"
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If paying by check:
The total cost of the weekend is $125.00. Please make your check out to Birmingham Emmaus
Community and return your check and signed application to your sponsor. (Checks will not be
deposited until the Monday after the Walk) If you do not have a sponsor, Print and mail the application
and registration fee to:
Birmingham Emmaus Community
P.O. BOX 100545
Birmingham, Alabama 35210
IF YOU DECIDE TO USE THE SECURE PAYPAL METHOD FOR PAYING YOUR FEE, JUST CLICK ON
THE PAYPAL BUTTON BELOW. BECAUSE THE PAYPAL METHOD IS ELECTRONIC BANKING, YOUR
PAYMENT WILL BE AUTOMATICALLY DEPOSITED IN THE BIRMINGHAM EMMAUS COMMUNITY BANK
ACCOUNT. IN THE RARE EVENT YOU CAN NOT ATTEND THE WALK AS SCHEDULED, YOU HAVE
THE OPTION OF BEING SCHEDULED ON A FUTURE WALK OR HAVE YOUR FEE REFUNDED MINUS
THE PROCESSING FEES PAYPAL CHARGES US (USUALLY 1.5%)
By typing my signature below I hereby authorize representatives of the Birmingham
Emmaus Community to act on my behalf according to their best judgment in any
emergency. In consideration for the acceptance of this Pilgrim’s application, I
hereby waive and release the Birmingham Emmaus Community from any and all
liabilities which may arise during my participation in a Walk to Emmaus.
Applicants Signature: Date:
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