Caterpillar Application Girls Flight #47

Caterpillar Application Girls Flight #47

Hello, thank you for considering being a caterpillar on an upcoming Chrysalis flight. Please fill out the information below and see that your sponsor fills out their form as well. Then, please mail your $30.00 registration deposit to our registrar at 2006 Baird Avenue, Portsmouth OH, 45662. This is to be applied to the total $60.00 cost of the flight. This deposit is nonrefundable. Please make your check payable to SOUTHERN OHIO CHRYSALIS. Fly with Christ!
Your Name *

First Name Last Name
Your Name Tag
This is what your name tag will have printed during the weekend.
Your Email *
example@example.com
Your Phone Number *
Please enter a valid phone number.
Sponsor's Name *
Full Name
Sponsor's Phone Number *
Please enter a valid phone number.
Your Street Address *
Your City *
Your State *

Ohio Kentucky West Virginia Indiana Other
Your Zip Code *
Your Birthday *

Month Day Year
Date
Your Current Age *
Your Gender *

Male Female
Your Shirt Size *

Small Medium Large X-Large XX-Large XXX-Large
Your High School or College (if applicable)
Your Grade *

Freshman Sophomore Junior Senior Post-Graduation
Your Church Name/City (if applicable)
Why do you want to participate in a Chrysalis Flight? *
Your Signature *

Clear
Emergency Contact Information

Please provide us some information regarding an emergency contact in case of serious situation. In the event of an emergency, if your emergency contact cannot be reached by the number provided, Chrysalis staff has permission to secure the services of licensed medical professionals to provide the care necessary, including anesthesia.
What is your emergency contact's name? *
Name
What is your emergency contact's phone number? *
Please enter a valid phone number.
Parent/Guardian Information

Please be sure that the information above is that of the caterpillar, and the information below is that of a parent or guardian.
Parent or Guardian Name *

First Name Last Name
Parent or Guardian Email *
example@example.com
Parent or Guardian Address (if differs from child)
Parent or Guardian Phone Number *
Please enter a valid phone number.
Please list any medical allergies, medications being taken, special diets, medical problems, or other pertinent information regarding the applicant.
Parent or Guardian Signature *

Clear
Parent or Guardian Information: In the event of an emergency, if your emergency contact cannot be reached by the number provided, Chrysalis staff has permission to secure the services of licensed medical professionals to provide the care necessary, including anesthesia. By signing this application, you are giving permission to Southern Ohio Chrysalis to list your child's name on the Southern Ohio Chrysalis website for prayer support purposes. Please mail a $30.00 registration deposit to our registrar at 2006 Baird Avenue, Portsmouth OH, 45662. This is to be applied to the total $60.00 cost of the flight. This deposit is nonrefundable. Please make your check payable to SOUTHERN OHIO CHRYSALIS.
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