Flights are for high school sophomores, juniors, and seniors (ages 15-18). Journeys are for ages 18-26.

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 conatct 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.

IMPORTANT: If your candidate is under 18 years old, you must have the parent/guardian fill out this permission form and mail or fax in, or bring to the registration table.

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

APPLICATION

Choose a Weekend Choose Option Journey 25 - Men - March 23-25, 2011 Flight 61 - Boys - March 23-25, 2011

 

Candidate Information

 

Candidate Name

 

Sex Choose Option Male Female

 

Phone Number

 

Age

 

Date of Birth

 

Home Address

 

School Address (if at college)

 

Email Address

 

School

 

Grade Choose Option High School Sophomore High School Junior High School Senior College Freshman College Sophomore College Junior College Senior College Graduate Career/Other

 

Name of Church now Attending

 

Pastor's Name

 

Has Pastor Attended a Chrysalis or Emmaus? Choose Option Yes No Don'T Know

 

List school Clubs and Activities

 

Are you on special medication or a diet?

 

Are you Vegetarian? Choose Option Yes No

 

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

 

Has Chrysalis Been Explained to You? Choose Option Yes No

 

What would you like to receive from this weekend?

 

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

 

Insurance Company

 

Policy Number

 

Doctor

 

Doctor's Phone

 

Sponsor's Section

 

Sponsor's Name

 

Sponsor's Address

 

Sponsor's Phone

 

Sponsor's Cellular Phone

 

Sponsor's Email Address

 

Sponsor's Church

 

Location and Date of YOUR Walk/Flight

 

Name of ReUnion Group Attending

 

How long have you known your candidate?

 

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

 

Are you willing to assist your candidate in finding a ReUnion group? Choose Option Yes No

 

Will you bring your candidate to registration? Choose Option Yes No

 

Will you attend sponsor's hour? Choose Option Yes No

 

Will you attend closing? Choose Option Yes No

 

Will you attend Follow-Up? Choose Option Yes No

 

Please enter the text at the right.