Candidate Application

Which weekend are you applying for?

Name:

E-Mail Address:

Street Address:

City:

State:

Zip Code:

Phone #:

(###) ###-####

Birthdate:

ex. 01/01/2000

Age:

Grade:

Sex:

Male       Female

School:

Church:

Pastor's Name:

Pastor's Phone #:

(###) ###-####

Religious/Community Organizations:

Has Chrysalis been explained to you?

Yes       No

Has the follow-up program been explained?

Yes       No

Do you need Scholarship Assistance?

Yes       No

State briefly why you want to participate in Chrysalis and what you expect:

Please list any allergies, medications, medical problems, special diet, or other pertinent information or restrictions:

Sponsor's Name:

Sponsor's E-Mail:

Sponsor's Address:

Sponsor's City:

Sponsor's State:

Sponsor's Zip Code:

Sponsor's Phone #:

(###) ###-####

Parent(s) Name:

Parent(s) E-Mail:

Parent(s) Address:

Parent(s) City:

Parent(s) State:

Parent(s) Zip Code:

Parent(s) Phone:

(###) ###-####

Emergency Contact Person's Name:

Emergency Contact Person's Phone #:

(###) ###-####

Additional Comments:

By pressing the "Submit" button below, you understand that you are applying for an upcoming Chrysalis Weekend. You or your sponsor are required to pay the $75.00 weekend fee, which offsets expenses such as food and lodging, unless you are applying for scholarship assistance. You will be notified of your acceptance and the dates of your weekend. Please notify us immediately if you cannot attend, since there may be a waiting list. You wil also be required to complete a Medical/Liability Release form, which will be e-mailed to you after pressing submit. You agree to print, sign, and return this form before your weekend begins. You will not be allowed to participate in the Chrysalis Weekend until this form has been returned.