NORTHWEST OHIO CHRYSALIS REGISTRATION
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:_____________________County:_________________Year of HS Graduation: __________
E-mail:________________________________  School you presently attend: __________________

Parent(s) names: _____________________________________ Parent Phone:(____)_____________
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: ______________________________________
__________________________________________________________________________________
School 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 $60.00* 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 Maumee UMC - Please Check Weekend Preference)
____ #19  June 20-22, 2008              _____ #19  August 1-3, 2008
____ #20  November 7-9, 2008         _____ #20 February 5-8, 2009