Richmond Area Chrysalis Community

<= ![endif]>Richmond<= /st1:place> Area Chrysalis Community

= &nb= sp; (Y= outh Walk to Emmaus) =

Chrysalis Flight # ___________<= span style=3D'mso-tab-count:3'> &= nbsp; &nbs= p; Prefe= rred name for name tag ___________________

Please PRINT

NAME:______________________= _____ADDRESS:____________________________ CITY:______________= ______________STATE:____ZIP:_______PHONE:__________

BIRTHDATE:__________AGE:___= ____GRADE:_________MALE:____FEMALE:____

Name and Denomination of church you attend: __________________________________

Pastor’s Name:_______= ____________________________________________________

In what religious or community organizations are you a= ctive? :______________________

______________________________________________________= __________________

In what school organizations are you activ= e?: _____________________________________

If employed, what is the nature of your employment?: ______________________________

Are you on a special diet? Explain: ____________________________________________

______________________________________________________= __________________

Why do you wish to be involved in Chrysalis and what d= o you expect from it?

______________________________________________________= ___________________________________________________________________________= _______________

YOUTH’S SIGNATURE: _________________________ DATE :__________________=

Sponsor’s Name: ________________________________= __ Sponsor’s Phone: _________

Sponsor’s Address:___= ____________________________________________________

TO BE COMPLET= ED BY PARENT OR GUARDIAN

_____________________ has my permission to attend the Chrysalis weekend.

In the event of an emergency and I cannot be reached by phone, the Chrysalis staff has my

permission to secure the se= rvices of licensed medical professionals to provide the care necessary, including = anesthesia, for my child’s well-being.

= PARENT’S SIGNATURE:_______________________________DATE:__________<= /b>

If above cannot be reached call:_____________________________Phone:___________=

Please list any medical allergies, medication being ta= ken, special diets.:_______________

Other information.:_______________________________________
______________________________________________________= _________________

The emergency= medical form that is attached MUST BE COMPLETED AND RETURNED WITH THIS APPLICATI= ON FOR IT TO BE PROCESSED.

All of the information above is necessary for proper placement in a Chrysalis Flight.<= o:p>

Please fill in all blanks. Enclo= se a $20 deposit, which will be applied toward your total fee, or= you may enclose the entire $60 fee. Make checks payable To: Richmond Area Chrys= alis Community. You will be notified of your acceptance and the dates and locati= on of your flight.

Mail completed application to:   Richmond Area Chrysalis Registrar<= /b>

        =             &nb= sp;            =             &nb= sp;      P.O. Box 1463        &= nbsp;

      &nb= sp;            =             &nb= sp;            =          Richmond, IN. 47375

        &= nbsp;           &nbs= p;            &= nbsp;

        &= nbsp;           &nbs= p;            &= nbsp;                    If you submit a deposit only, please bring $40 with you to the flight.

(BACK MUST BE COMPLETED ALSO)

Candidate should give this form to Pastor, youth couns= elor or a teacher who know him/her well.

This form will help us to place the candidate in a gro= up where they will benefit the most.

This information will be kept in STRICT CONFIDENCE.

CANDIDATES= 217; NAME :________________________________________________= ______________

School :________________________= City :___________________________ Grade :_____________

YOUR NAME :_________________________ ADDRESS :__________________________________

CITY :________________________= __ STATE :________________________ Ph.= # _____________

How long have you know the candidate? __________________________________________________

In what capacity? _____________________________________________________________________

Please circle the appropriate response and comment as necessary.

Chrysalis is a religious experience for youth who have GRADUATED FROM THE NINTH GRADE, AND REMAIN ELIGIBLE THROUGH THE SUMMER AFTER THEIR GRADUATION FROM HIGH SCHOOL. (15-19)=

Exercise of Leadership        =             &nb= sp;     None     &= nbsp;      Poor        =       Good     &= nbsp;     Excellent

Comments:__________________= ________________________________________________________

______________________________________________________= _____________________________

Areas of Leadership        =             &nb= sp;        School        = Church        = Athletics    &n= bsp; Other

   &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;            =           Social        =     Student         Drama        =    Music

Comments : _________________________________________________________________________
______________________________________________________= _____________________________

Maturity   &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;         Low        =        Average    &nbs= p; Mature        =    Very Mature

Comments : _________________________________________________________________________
______________________________________________________= _____________________________

Psychological adjustment        =              Poor        =       Average        Good        =       Excellent

Comments : _________________________________________________________________________
______________________________________________________= _____________________________

Peer Relationships&nbs= p;            &= nbsp;           &nbs= p;      Quiet        =      Talkative    &n= bsp; Well-liked    &= nbsp; Domineering

Comments : _________________________________________________________________________
______________________________________________________= _____________________________

            =         Please furnish any other information that would be helpful for the team.

   &nbs= p;                 Comments a= bout the candidate’s home life, interest, difficulties or hopes

   &nbs= p;                 would be of great help. THANKS FOR YOUR TIME AND INTEREST.

SPONSOR’S NAME : ____= __________________________ ADDRESS : ________________________

CITY : ___________________________ STATE : ____ ZIP : ______________ Ph. # _______________

Have you served as a sponsor before? _____________________________________________________

Are you willing to pray and sacrifice for your butterfly? _______________________________________

How long have you known the youth? _____________________________________________________

Will you bring your butterfly to the weekend? __________________________________= ____________

Will you take your butterfly home? _______________________________________________________

Will you attend sponsor’s hour? ___________ Candlelight : ________________ Closing : ___________
Will you accompany your butterfly to the first gatheri= ng? __________________________________= ____

Will you help find your butterfly a sharing group? ____________________________________________

Any additional comments : _____________________________________________________________

______________________________________________________= _____________________________

______________________________________________________= _____________________________

______________________= __________________________________________________