Emmaus Application

THE APPLICATION PROCESS

Have your Passport available.
If your application information is incomplete at this time please provide the requested information to Emmaus by separate email when the information becomes available. Do not submit a second online application.
At the end of the Application process you will be given an opportunity to Print a copy of your Application.

PROGRAM INFORMATION

Program Destination:

Program Departure Date:

PASSPORT INFORMATION

EXACTLY as it appears on your passport.

Passport First Name:

Passport Middle Name:

Passport Last Name:

Passport Country:

Passport Number:

Passport Date Issued:

Passport Date Expires:

Date of Birth:

GENERAL INFORMATION

Title:
Gender:
Marital Status:
Current Age:
Nickname:
Street Address:
City:
State / Province:
Country:
Zip / Postal Code:
Home Phone:
Cell Phone:
Email Address:

MEDICAL INFORMATION

Check all that apply:

	Do you have a heart condition or pacemaker?
	Are you diabetic?
	Are you currently under a doctor's care for a medical condition?
	Are you allergic to any food, food related item, stings, etc.?
	Do you wish to have Vegey meals?

If you placed a check above, please offer a brief explanation and offer a statement of treatment:

$300 DEPOSIT FEE REQUIRED

Please make your check payable to Emmaus Educational Services. No credit card payments are accepted.

EMERGENCY CONTACT PERSON / DOCTOR

In the event of a medical emergency, whom do you wish Emmaus to contact?

Name:
Relationship:
Phone:
Doctor's Name:
Doctor's Phone:

MEDICAL INSURANCE

All participants are required to have medical coverage when on an Emmaus program. No exceptions are allowed. Your existing personal medical insurance likely covers you for overseas travel. Check your policy or contact your personal insurance agency for verification of coverage. If you do not currently have coverage, please inform Emmaus when the required insurance is obtained. Additional information can be found in the Notes section of your program's web material.

Do you currently have medical insurance for international travel?

HOTEL ACCOMMODATIONS

Single room supplemental fees range from $500-$1000. Inquire.

Select Room Occupancy:
Name of Spouse or Roommate:

PASSPORT PHOTOCOPY

A photocopy of the "picture" page of your passport is required. Be sure the photocopy is of sufficient quality to serve as a secondary photo ID. As an option you may send a scan by email. No fax copies accepted.