| EPISCOPAL CURSILLO MOVEMENT of the DIOCESE OF WESTERN NEW YORK CANDIDATES APPLICATION FORM (Please Print) NAME_______________________________________PHONE_____________________ NICKNAME IF USED (if used)_______________________AGE__________ SEX_____________ MARITAL STATUS___________________ SPOUSES NAME_____________________________ ADDRESS_________________________________________________________________________- MAILING ADDRESS (if different)_____________________________________________________ CITY________________________________________ZIP CODE_____________________________ OCCUPATION________________________________EDUCATION___________________________ PARISH NAME & LOCATION________________________________________________________ PARISH ORGANIZATIONS___________________________________________________________ COMMUNITY ACTIVITIES___________________________________________________________ HOBBIES___________________________________________________________________________ RENEWAL ACTIVITITIES ATTENDED OR PARTICIPATED IN ___________________________ ____________________________________________________________________________________ WHY DO YOU FEEL THAT YOU WOULD LIKE TO MAKE A CURSILLO WEEKEND? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ HAS THE FOLLOW UP PROGRAM (4TH DAY) BEEN FULLY EXPLAINED TO YOU? ________ DO YOU HAVE ANY QUESTIONS ABOUT CURSILLO?____________________________________ ____________________________________________________________________________________ DO YOU HAVE ANY HEALTH PROBLEMS WE SHOULD BE AWARE OF? If it could cause a problem, we must know about it in advance, e.g. All medication (include food which needs to be taken with medication and timing requirements), breathing problems, mobility problems etc. We try to arrange for a nurse to be present and this information is vital. If you have any limitations, medical or physical, please share these. YES____NO_____ MEDICATIONS__________________________________________________ ____________________________________________________________________________________ SPECIAL DIET?______________________________________________________________________ ALLERGIES?________________________________________________________________________ OTHER?_____________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ I WOULD LIKE TO BE CONSIDERED AS A CANDIDATE FOR THE NEXT CURSILLO WEEKEND. SIGNATURE_____________________________________ |