Channel Islands Chrysalis Community Southern California -- United States


		Flight Dates/Location
		Lay Directors

		Release Form
		Authorization for Background Screening

Reminder

Please make sure you complete all of the information requested. Remember, you must also complete a Medical/Liability Release Form prior to your Chrysalis Weekend. If you are under 18, your parents must also sign the form.

Team Application

Please complete the following:

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:

Applying As:

Adult Youth

Have you worked Team?

Yes No

Is there anything that would limit you from serving in a certain task on the team?

State briefly why you wish to participate as a team member in Chrysalis and what you expect:

Please indicate the talks that you have given (check all that apply):

Ideals	Marriage
God Designed You	God Forgives You
Faith	Christian Action
God Loves You	Single Life
The Prodigal	God Empowers You
Communication Through Prayer	Priesthood of All Believers
Christian Growth Through Study	Next Steps
God's Gift to You	Other:

Please indicate the positions in which you have served on previous weekends:

Lay Director	Assistant Head Cook
Assistant Lay Director	Cook
Head Spiritual Director	Head Agape
Spiritual Director	Agape
Table Leader	Logistics
Head Musician	Angel
Musician	Candlelight Dinner Server
Head Cook	Other:

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

Have you or your parent(s) signed and returned the Medical/Liability Release Form?

Yes No

Have you signed the Authorization for Background Screening documents? (if you are 18 years of age or older)

Yes No Under 18 (Does Not Apply)

Do you have any interest in serving on the Channel Islands Chrysalis Community Board of Directors?

Yes No

Additional Comments:

By pressing the "Submit" button below, you agree that if you are selected to serve on a team, you will attend team meetings and participate in the entire weekend. You will be required to pay the $75.00 team fee, which offsets expenses such as food and lodging, unless you are applying for scholarship assistance. You will also be required to complete a Medical/Liability Release form, which will be e-mailed to you after pressing submit. In addition, you will be required to complete an Authorization for Background Screening, and in doing so, you give your unrestricted permission for the Channel Islands Chrysalis Community to investigate and make an inquiry into your background, including but not limited to your criminal history. Complete details regarding Background Screenings can be found in the Phase I Background Screening Policy. You agree to print, sign, and return these forms prior to any participation in team events. You will not be allowed to participate in the team activities until these forms have been returned.