Big Country Emmaus community now has the newest version of this form online at http://www.bigcountryemmaus.org/Big_Country_Emmaus_Application.pdf. My version of the form (below) is outdated. Please use it only if you can't access or print the one on the community site.
Big Country Community Walk to Emmaus/Chrysalis Flight Request for Reservation Flease type or print neatly and fill out all information on this application and return it to your sponsor. This form, your completed sponsor form, and payment in full should be mailed to the Registrar's office listed below. *Walk requested: (Choose One) ____Men's/Women's Emmaus Walk Date of 1st Choice____________Walk/Flight #_____ ____Young Men's/Young Women's Journey Date of 2nd Choice____________Walk/Flight #_____ ____Boy's/Girl's Chrysalis Flight Can you attend on short notice of 3-4 days Yes__ No__ Has the Emmaus Walk/Chrysalis Flight been explained to you, including the post-Emmaus follow-up?___________________________ *Last Name______________________________*First Name____________________ Nametag name_____________________________ *Address___________________________________City_______________________State_______Zip___________________ *Home Phone(_______)________________________Business phone(______)________________*Birthdate_________________ *Present Occupation __________________________________*Church now attending________________________________________ ____Male *Name and phone number of someone to contact in case of emergency and/or that will know how to contact ____Female you at all times prior to your Walk/Flight/Journey ____Married Name________________________________________Phone No.________________________________ ____Single ____Divorced If you are a high school student, please indicate your grade level at the time of the Flight: ____Widow(er) Soph.__________ Jr.____________ Sr._______________ Age_____________ ____Children -#______
* HEALTH RELEASE FORM FOR APPLICANTS OF EMMAUS WALKS/CHRYSALIS FLIGHTS Please list all allergies, medications being taken, medical problems, special diets, physical handicaps, or other peritnent information that may affect your attendance and well being at a Walk to EmmauslYoung Adult Flight. In the event of an emergency, and if my closest relative and/or spouse cannot be reached by telephone, the Emmaus staff has my permission to gain the services of licensed medical professionals to provide the care deemed necessary, including anesthesia, for my well being. Your Signature _______________________________________________Date_______________________________ To be completed by parent/guardian if applicant is in high school:____________________________ has my/our permission to attend the Chrysalis weekend. In case of emergency, and if I/we cannot be reached by telephone, the Chrysalis staff has my/our permission to gain the services of licensed medical professionals to provide the care deemed necessary, including anesthesia, for my child's well being, the cost for which I shall be responsible. Parent/Guardian Signature_______________________________________Phone______________________ Date of applicants last Tetanus shot______________ Name of Insurance Company and No___________________________________. If the above cannot be reached, please call _____________________________________________________________________
*All starred items must be completed, Register ONLY if you intend to be present for the entire weekend. Sponsor should already have been on a Walk to Emmaus, Chrysalis, or Cursillo or other similar weekend. NO application will be accepted without the following items: 1) Completed and signed application, 2) Completed sponsor's form, 3) Payment in full-($130.00). Make checks payable to "Big Country Emmaus Community. " No post dated checks will be accepted. Please mark the outside of the envelope "Men's", "Women's" or "Chrysalis" and mail to: Emmaus Registrar's Office, P.O. Box 5080, Abilene. TX 79608. *Applicant's signature_________________________________*Applicant's pastor's signature_________________________________ *Sponsor's signature__________________________________*Sponsor's name (print)_______________________________________ *Sponsor's Address_________________________________*City_________________________*State________ *Zip____________ *Sponsor's Home phone(____)_______________________ Business phone(____)____________________________________________ *If primary sponsor is a high school student, an adult co-sponsor (21 years of age or older) must sign below: *Co-Sponsor's signature___________________________________Address____________________________Phone no.______________
Office Use Only- Confirmed on Walk/Flight*_________Date_________________Waiting list Walk/Flight*___________Date________ Amt. recd__________Check* BY_______________ Schol. amt_________Appl. date__________ Letter mailed_____________