January 19, 2012:  Girls Chrysalis Flight (high school)
January 26, 2012:  Boys Chrysalis Flight (high school)

July 19, 2012:  Girls Chrysalis Journey (college age)
July 26, 2012:  Boys Chrysalis Journey (college age)

If the candidate is younger than 18, don't forget to print the parental consent and mail it in as soon as possible. Also, you will need your sponsor's information!!!

This online application is for your convenience.   When you click submit, it will e-mail the application to me and you will receive a confirmation e-mail telling you I received it.   If you have any questions please e-mail me at chrysalisregistrar@live.com. 

IT IS VERY IMPORTANT THAT YOU PRINT THE PARENTAL CONSENT/MEDICAL WAIVER AND MAIL IT TO ME AS SOON AS POSSIBLE!!   YOUR APPLICATION WILL NOT BE ACCEPTED UNTIL THE CONSENT/WAIVER IS RECEIVED!!!!

  1. Please provide the following contact information:

    Name
    Street Address
    Address (cont.)
    City
    State/Province
    Zip Code  
    Home Phone
    E-mail

  2. Please select the walk you are applying  to attend:

          

  1. Other Information

    Date of Birth   (Required)
    Sex Male Female

  2. Enter your T-Shirt Size.


  3. What grade are you or what year are you in college:


  4. What Church do you attend?


  5. What school do you go to? (If none, type none)


  6. Please List your School/Church Activities.


  7. Do you require special meals? (If yes, please explain)


  8. Do you have any health problems that might affect your participation in Chrysalis? (If yes, please explain)


  9. Do you take any special medications? (If yes, please list the medicaitons and the times you take them)


  10. State briefly why you wish to attend Chrysalis and what do you expect from it?


  11. Please provide the following information for your Sponsor (someone who has been through Chrysalis or the Walk to Emmaus):

    Name  
    Street Address  
    Address (cont.)
    City  
    State/Province  
    Zip/Postal Code  
    Home Phone  
    Other Phone
    E-mail

Please don't forget to print and send in the parental consent if you are under the age of 18.