Pilgrim Application

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*Denotes required field.

To Be Completed by Pilgrim/Applicant:

Please ensure that a $50.00 non-refundable deposit toward the $165.00 fee, payable to G.R.A.C.E. Community will be sent to Grace Registrar

*Full Name: *Name for Name Tag:
Are You Clergy?:

Gender:

*Email:
*Home Phone: *Cell Phone:
Street Address: City:
State: Zip Code:
Date of Birth: Marital Status?:

*Are you on a special diet or medication?       

*If so, please specify diet needs/list medications:
*Do you have a health or physical limitation that may affect your attendance:

*If so, please specify:

  Completion of the Church and Pastor information below confirms that the Pastor supports the Pilgrim's participation in this walk.

*Church Name: *City:
Denomination: *Pastor's Name:

Emergency Contact #1: Phone:
Emergency Contact #2: Phone:
Has the Walk been explained to you?:

If married, was it explained to your spouse:

To Be Completed by Sponsor:

*Full Name: *Email:
*Home Phone: *Cell Phone:
Street Address: City:
State: Zip Code:
Community/Date of your Walk: Walk Number:
Security Question:


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