Chrysalis Application

A CHRYSALIS Weekend is a three day experience which takes a look at Christianity as a lifestyle. It is a highly structured weekend designed to strengthen and renew the faith of young Christians and, through them, all those with whom they come into contact. CHRYSALIS is an ecumenical, combined effort of laity and clergy toward renewal of the Church.

Sponsor's Name*
First Last
Sponsor's phone number*
Emergency Contact Information
Emergency Contact (if above can not be reached)*
First Last
Emergency Contact's phone number*
Emergency Contact's Email

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Please list any allergies (medical, food, etc.) medications, special diet, medical problems, etc.
Please enclose $15 as a non-refundable deposit, to be applied toward the $65 registration fee,which partially offsets the expense of the weekend. Make check payable to FINDLAY AREA CHRYSALIS.

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FOLLOWING TO BE COMPLETED BY PARENT OR GUARDIAN (if candidate is under 18)
Name*
First Last
has my permission to attend the Chrysalis weekend. In the event of an emergency and I/we cannot be reached by phone,the Chrysalis staff has my permission to secure the services of licensed medical professionals to provide the care necessary,including anesthesia,for my child's well-being. BY SUBMITTING THIS APPLICATION YOU HAVE AGREED TO THE ABOVE ! PLEASE TYPE YOUR NAME IN THE SPACE BELOW*
Phone*

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Chrysalis Application

Chrysalis Application

Personal Information

Religious Information

Emergency Contact Information

FOLLOWING TO BE COMPLETED BY PARENT OR GUARDIAN (if candidate is under 18)

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