Please complete the information below so we can best meet your
needs on your Chrysalis weekend.
All information will be kept confidential. Upon completion, return the form to
your sponsor.
Name: _______________________ Sex
(circle): M F
Name for Nametag: ______________
Address:______________________________________
T-shirt size (circle): S - M - L -
XL - XX
City: _______________________
State:____ Zip:________ Date of birth:
____________ Age____
Phone: (H)______________(Cell)___________County:___________Year
of HS Graduation: _____
E-mail:________________________________ School
you presently attend: __________________
Parent(s) names:
___________________________ Parent Phone:
(H)___________Cell __________
Parent email address:
____________________________________________
Parent address:
______________________________________City__________State____
Zip______
If above cannot be reached contact :
_______________________________ Phone:
____________
Name / denomination of Church you attend:
____________________________________________
Church address:
_____________________________City:
___________State: _____Zip: _________
Pastor's name:
_________________________________________ Phone:(___)__________________
Pastor's email address:
____________________________________________
Church or community activities you are involved in: ______________________________________
__________________________________________________________________________________
Has the Chrysalis weekend been explained to
you? Y / N The
follow-up activities: Y / N
State briefly why you wish to participate in Chrysalis and what you expect
from it: __________________________________________________________________________________
__________________________________________________________________________________
Please list any allergies (medical, food, etc.), medications, special diet,
medical problems, etc.:
______________________________________________________________
__________________________________________________________________________________
Sponsor's Name: ___________________ Youth's
Signature: ____________________ Date: _________
Please enclose $15.00 as a non-refundable deposit toward the $65.00*
registration fee, which partially
offsets the expense of the weekend. Make check payable to NORTHWEST OHIO
CHRYSALIS.
You will be notified of your acceptance, the dates and location of your Chrysalis
weekend. Thank you!
(* Partial and full scholarships are available if needed. ___ Yes,
partial / full scholarship is needed.)
FOLLOWING TO BE COMPLETED BY PARENT OR GUARDIAN (if candidate is
under 18) _________________________has my permission to attend the Chrysalis
weekend. In the
event of an emergency and I/we cannot be reached by telephone, the Chrysalis
staff has my permission
to secure the services of licensed medical professionals to provide care
necessary, including anesthesia
for my child's well-being.
Signature of Parent/Guardian
_____________________________ Phone
__________________
Girls' Weekends ___________________Boys'
Weekends
(All weekends are held at
____ #23
____ #24