chrysalis logo Cross Bayou High School Chrysalis Application

Name    Nametag name
Address   City         State    Zip
School Date of graduation T-Shirt size
Male Female      Date of Flight Flight Location

PARENT / GUARDIAN Name(s)  
Phone (Home)  Alternate Number

ALTERNATE EMERGENCY CONTACT

NAME                                               PHONE                             RELATIONSHIP
yes no - Have you been informed to expect NO outside contact during the weekend, except in an emergency?
yes no - Has it been explained to you that all flights are SMOKE FREE events?

I, the parent/guardian, give my son/daughter permission to attend this Chrysalis Three Day Weekend.


Parent / Guardian Signature                                 Date


Participant's Signature                                         Date

NOTARY REQUIRED IF APPLICANT IS UNDER 18

Subscribed and sworn to before me, (Name of Notary)

A Notary Public, in Parish/County, Louisiana/Texas

the day of , 20

Signature of Notary Public

My Commission expires

RETURN FORM, COPY OF INSURANCE CARD & PAYMENT TO YOUR SPONSOR

 

chrysalis logoCross Bayou High School Chrysalis Application

MEDICAL AUTHORIZATION - REQUIRED BY ALL APPLICANTS REGARDLESS OF AGE


I am the parent/guardian of

During the event I can be reached at
Please give a telephone number and alternate number

Doctor's NamePhone Number

Insurance ProviderPhone Number

PLEASE PROVIDE PHOTO COPY OF INSURANCE CARD, FRONT AND BACK

Participant's SSN#
(This is needed in the case of emergency treatment)

Date of last Tetanus shot

Are there any medications to be taken during the weekend? yes no
List Medication

List Allergies    

Explain any special dietary requirements


Describe any health accommodations that might be needed.  This includes physical, mental, spiritual or emotional.  All information is confidential



COST OF FLIGHT IS $100.00.

Make all checks payable to Cross Bayou Chrysalis,

THIS FORM, A COPY OF INSURANCE CARD & PAYMENT MUST BE RETURNED TO YOUR SPONSOR

 

chrysalis logo Cross Bayou High School Chrysalis Application

Your Name Phone Number    
Address   City         State   Zip  
Email Address  Your church    
Three day weekend that you attended  
When   Where?
   Walk / Flight #     

yes no - Does your candidate have the physical and mental health needed for Chrysalis Flight weekend?
yes no - Have you informed the candidate that they should expect to have NO outside contact during the weekend, except in case of emergency?  
yes  no - Have you explained that all flights are SMOKE FREE events? 
yes no - Will you personally bring the candidate to the site?
yes no - Are you praying for your Candidate?
yes no - Help your candidate get into a reunion group?
yes no - Have you explained the follow up meeting?

As a sponsor, are you willing to say "YES" to Christ - to fulfill your responsibilities so that His grace and love are revealed through your actions? 

CONFIDENTIAL INFORMATION FOR LAY AND / OR SPIRITUAL DIRECTORS

Why did you sponsor this person for a Chrysalis Flight?  

If possible, describe your candidate's personality, spiritual growth, etc. to asist the team in seating and room assignments.


Mail Completed forms and fees to:
Bonnie Keene - Female Registrar Donna Kemp - Male Registrar
110 Peaceful Bay 4778 Dorcheat Rd.
Homer, La. 71040 Minden, LA 71055 email dkbkemp@yahoo.com
Phone (318) 245-1792 Phone (318) 377-4428 (H) (318) 422-7589 (C)