Apply for a Chrysalis Weekend

Flights are for high school sophomores, juniors, and seniors (ages 15-18).

The candidate must fill out the top portion of this application and the sponsor must fill out the bottom portion.

Please DO NOT submit an incomplete application.

If information is left off this application, it will not be accepted. If you do not list your contact information, there's no way for us to confirm this application with you.

If you can't fill out in person together but still wish to submit your application online, contact your candidate to get the information below or Download the Paper Application.

Please notify us immediately if you cannot attend, others on a waiting list may be able to attend if contact soon enough to prepare.

Chrysalis Application

Candidate Section

Weekend Date

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Candidate Name(*)

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Gender

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Phone Number

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Age

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Date of Birth

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Home Address (with City, State, and Zip Code)

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School

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Church now Attending

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Pastor's Name

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Has Pastor Attended a Chrysalis or Emmaus?

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List School Clubs and Activities

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Are you on special medication or a diet?

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Are you Vegetarian?

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Do you have any health problems or physical handicap that may affect your attending?

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Has Chrysalis Been Explained to You?

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What would you like to receive from this weekend?

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Please list any medical allergies, medications being taken, medical problems or other pertinent information

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Insurance Company

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Policy Number

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Doctor

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Doctor's Phone

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Name of ReUnion Group Attending

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How long have you known your candidate?

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Why do you feel this person would be a good candidate?

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Are you willing to assist your candidate in finding a ReUnion group?

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Will you bring your candidate to registration?

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Will you attend sponsor's hour?

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Will you attend closing?

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Will you attend Follow-Up?

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Chrysalis Application

Candidate Section

Sponsor Section

Calendar