Applicant information (please print)
Last Name First Name MI
Name you wish to appear on name tag Male / Female
Address Phone
City State Zip
Age Birthday / / School ______ Grade Completed
Applicant Signature _______ Date __________
Preparatory Questions:
Has the Chrysalis weekend been explained to you?
Have the follow-up gatherings been explained to you?
On the back of this form, please state briefly why you wish to participate in Chrysalis.
Pastoral Information:
Name and denomination of church /
Pastors Name Youth Pastors Name
Church address Phone
Medical and Parental Information (Applicants under 18 must have parent/guardian signature)
Parent/Guardian Name Phone
Address City
State Zip
On back of form please list medical allergies, medications being taken, medical problems, special diet, or other pertinent information. If parent or legal guardian cannot be reached please call
Phone ____________________Relationship .
(Name) has my permission to attend the Chrysalis weekend. In the event of an emergency and if I 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. We further do hereby release and discharge Chrysalis, its Board and members from any and all liability from illness, injuries, and damages that may arise out of or resulting from my child' s participation in or traveling to and from this event.
Parent/Guardian Signature Date
Completed Applications: Please provide this application to your sponsor with the $50 registration fee to cover the costs of the weekend. All costs inclusive. Please make checks payable to: Show Me the Way Chrysalis. You will be notified of your acceptance and the date, location and time of your weekend.
NOTE: please notify the registrar immediately if you are not able to attend this flight, others may be on a waiting list.
Registrar: Erika Huskamp 417.637.5524 or 417.880.1452 ehuskamp@msn.com