EmailMeForm
Chrysalis Flight Reservation (Must be Age 15-19)
This portion of the Application should be completed by the CANDIDATE.
If you are looking for the Sponsor Application, please copy the following address into your address bar:
http://www.emailmeform.com/builder/form/UArh6gm213dle2k0s
Personal Information
Please fill out all fields regarding information about you (The Candidate).
Name
*
First
Last
Preferred Name on Nametag
First
Last
Gender
*
Male
Female
Birthdate
*
MM
/
DD
/
YYYY
Phone
*
###
-
###
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####
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Email
*
Confirm Email
Do You Have A Job?
*
Yes
No
School Information
Please fill out all fields regarding information about your school.
School
*
Grade
*
Clubs/Organizations You Are Involved In
Church Information
Please fill out all fields regarding information about your church.
Church You Attend:
Denomination:
Pastor's Name:
Church/Religious Organizations You Are Involved in:
Chrysalis Weekend Information
Please fill out all fields regarding information about the Chrysalis weekend.
Has the Chrysalis Weekend Been Explained to You?
*
Yes
No
Have the Follow Up Programs of Group Reunions and Gatherings Been Explained to You?
*
Yes
No
If you are on special medication or have special diet needs please list them:
If you have health problems or physical disabilities that may affect your attendance, please list them:
Please briefly state why you want to go on Chrysalis, how you would be a part of the community, and what you expect to receive from the weekend:
*
There are no cellphones, radios, CD's, CD Players, MP3 Players, iPods, or Portable Game Systems allowed on the weekend. Have you read and understand this?
*
Yes
No
Dress Code: Any garment below the waist, including but not limited to shorts or skirts, must be approaching the knee. Spaghetti Straps/String Tops ARE NOT ALLOWED. Muscle shirts can be worn only with a shirt worn underneath them. Undergarments should be hidden at ALL times. The belly and back should never be exposed. This dress code applies during the whole weekend, which includes sleepwear and athletic clothing. Refusal to abide by this code will result in the candidate being asked to switch clothes. Further refusal will result in dismissal from the weekend. Have you read and understand this?
*
Yes
No
By typing your name to the right, you are signing and confirming that you have provided the most accurate information and you agree with all policies/rules in regard to the upcoming weekend.
This completes the CANDIDATE portion of the application. Please verify you have filled out all required fields and then click submit to proceed to the PARENT section of the application.