Paquimé, Chihuahua, was the ceremonial center of the Medio period (AD 1200 to 1450) Casas Grandes world, and the focus of regional pilgrimages. We use a relational perspective to explore the connections that were created and expressed during the pilgrimage. We propose that Paquimé was considered a living city, and that pilgrims actively supported its vitality through offerings of marine shells and other symbolically important goods. A region-wide network of signal fires centered on Cerro de Moctezuma, a hill directly overlooking Paquimé, summoned pilgrims. Ritual negotiations also focused on the dead and may have included at least occasional human sacrifice. While the pilgrimages focused on water-related ritual, they also included community and elite competition as reflected in architectural features such as the ball courts. Central to the pilgrimage was negotiation with the horned serpent, a deity that controlled water and was associated with leadership throughout Mesoamerica and the Southwest. The horned serpent is the primary supernatural entity reflected at the site and in the pottery pilgrims took with them back to their communities. Thus, the pilgrimages were times when the Casas Grandes people created and transformed their relationships with each other, religious elites, the dead, the landscape, and the horned serpent. These relationships in turn are reflected across the region (e.g., the broad distribution of Ramos Polychrome). This case study consequently demonstrates the potential that the relational perspective presented throughout this issue has for providing insight into the archaeological record and the past social structures it reflects.