2023 Jerome/Rohwer Pilgrimage Registration

PLEASE FILL OUT ONE FORM FOR EACH PERSON ATTENDING THE PILGRIMAGE IN PERSON IN LITTLE ROCK

Name (as you would like it to appear on your name tag)

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Email

EMERGENCY CONTACT INFORMATION

Emergency Contact (not traveling with you)

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Emergency Contact Email

Do you have any medical conditions, food allergies or special needs that we should be aware of?

Pilgrims are advised that personal services and devices such as wheelchairs and oxygen will not be provided. Pilgrims in need of services of a personal nature are responsible for arranging for such services prior to registering for the pilgrimage and are encouraged to travel with a companion for such purposes.

If you are traveling with a group, please list the names of everyone traveling with you.

If you are traveling alone, would you like to be paired up with another pilgrim/s as a travel buddy?

Yes

No

Pilgrims are responsible for booking their own hotel and flight.

What information would you like to appear on the public contact list?

Check all that apply

Name

Phone#

Email

The registration fee is now $300 because registration officially ended on March 31. Those 80 years of age and over may register free of charge. Your registration fee will cover dinner on May 3, 4, and 6, as well as bus transportation from Little Rock to McGehee.

Pilgrims over the age of 80 may register free of charge. Are you a senior over 80?

Yes

No

Please make checks out to “Japanese American Memorial Pilgrimages” and mail to:

Jerome/Rohwer Pilgrimage
411 Dufour Street
Santa Cruz, CA 95060