Online Application

 

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Heart of Georgia Chrysalis 

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.   After submitting the form a parental consent/Medical Waiver form will appear.  Please fill this out and mail it to me as soon as possible.  If you have any questions please e-mail me at registrar@hogchrysalis.org .

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.

Copyright © 2005 [Heart of Georgia Chrysalis]. All rights reserved.
Revised: June 12, 2006