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_____________