*Denotes required field. |
*Full Name: |
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*Name for Name Tag: |
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Are You Clergy?: |
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Gender: |
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*Email: |
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*Home Phone: (000)000-0000 |
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Cell Phone: |
(000)000-0000 |
Street Address: |
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City: |
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State: |
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Zip Code: |
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Date of Birth: |
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Marital Status?: |
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*Are you on a special diet or medication?
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If so, please specify diet needs/list medications: |
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*Do you have a health or physical limitation that may affect your attendance: |
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If so, please specify: |
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Emergency Contact #1: |
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Phone: |
(000)000-0000 |
Emergency Contact #2: |
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Phone: |
(000)000-0000 |
*Has the Walk been explained to you?: |
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If married, was it explained to your spouse: |
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Pilgrim's Signature:
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X
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*Church Name: |
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*City: |
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Denomination: |
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*Pastor's Name: |
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Pastor's Signature:
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X
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*Full Name: |
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*Email: |
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*Home Phone: (000)000-0000 |
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Cell Phone: |
(000)000-0000 |
Street Address: |
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City: |
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State: |
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Zip Code: |
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Community/Date of your Walk: |
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Walk Number: |
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Sponsor's Signature:
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X
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