Mountain Ridge Chrysalis

Fri, Oct 15 09:00AM - Sun, Oct 17 04:30PM

Fri, Nov 12 09:00AM - Sun, Nov 14 04:30PM

Sat, Jan 15 09:00AM - Mon, Jan 17 04:30PM

Fri, Mar 25 09:00AM - Sun, Mar 27 04:30PM

Fri, Oct 14 09:00AM - Sun, Oct 16 04:30PM

Fri, Nov 11 09:00AM - Sun, Nov 13 04:30PM

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.

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.

Choose a Weekend *

Candidate Name *		Please type as you want to appear on the nametag

Sex *

Phone Number

Date of Birth *

Age *

Home Address *		(Street, City, State, Zip Code)

School Address (if at college)		(Street, City, State, Zip Code)

Email Address

School

Grade

Name of Church now Attending *		If not currently attending, please use this area to describe the reason.

Pastor's Name

Has Pastor Attended a Chrysalis or Emmaus?

List school Clubs and Activities

Are you on special medication or a diet?		Please explain in detail.

Are you Vegetarian? *		(If Yes, Please explain above)

Do you have any health problems or physical handicap that may affect your attending?		(If Yes, Please Explain)

Has Chrysalis Been Explained to You? *

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		This information is very important in case of emergencies!

Policy Number

Doctor

Doctor's Phone


SPONSOR'S SECTION
	This information is required. If you submitted another online application for this same weekend, just put your name and we'll add your contact info.

Sponsor's Name *

Sponsor's Address		(Street, City, State, Zip Code)

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?

Will you bring your candidate to registration?

Will you attend sponsor's hour?

Will you attend closing?

Will you attend Follow-Up?


After submitting this application, you will be taken to a payment page if you wish to pay online. If not paying online, the full amount is due at registration.

Mountain Ridge Chrysalis is a part of Blue Ridge Emmaus, a non-profit ministry under IRS Ruling 501(c)3. As such, all donations are tax-deductible
Copyright © 2004-2009 Mountain Ridge Chrysalis. All Rights Reserved.

SPONSOR'S SECTION