CHRYSALIS Applicant Central Alabama

Central Alabama Chrysalis Application
$135 is charged for the weekend. Complete and return this form, including a $75.00 non-refundable and non-transferable, reservation deposit, payable by Venmo @Emmaus-1 or by check. The balance of $60 will be due on the first night on which you are scheduled to attend. If paying by check, make check payable to: Central Alabama Emmaus Community (CAEC) and write CHRYSALIS on the memo line. Mail check and application to: Central Alabama Emmaus Community, c/o: Chrysalis Registrar, P. O. Box 241571, Montgomery, AL 36124. Please direct any questions to the Registrar, Sharon Truman at 334-354-4382 or sharontruman520@gmail.com.
1. TO BE COMPLETED BY THE APPLICANT - PLEASE PRINT CLEARLY.
Name*

First NameLast Name
Name for Name Tag:
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number
Date of Birth:*
MMDDYYYY
Current Age*
Enter Age at this time
Male or Female:*

MaleFemale
T-Shirt Size:*
S, M, L, XL, XXL
Applicant's E-mail
Please provide an e-mail.
Home Church Name
Denomination
School Name:
Current Grade*
State briefly why you wish to participate in Chrysalis:
2. TO BE COMPLETED BY THE APPLICANT'S PARENT or GUARDIAN - PLEASE PRINT CLEARLY.
Please list any allergies (medical, food, etc.), medications, special needs, physical and/or mental health concerns or any other pertinent information: Please sign\type name here.
The above applicant has my permission to participate in a Chrysalis Flight. In the event of an emergency and I cannot be reached by phone, I authorize an adult, in whose care the minor has been entrusted to, the right to consent to medical treatment for my child. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with any necessary medical treatment. In the event my child needs over-thecounter (OTC) medication* or prescription medication*, I authorize the entrusted individual to administer said medication. Should it be necessary for my child to return home due to medical reasons or otherwise, the undersigned will assume all costs. I further do hereby release and discharge Central Alabama Chrysalis, its Board and members from any and all liability from illness, injuries and damages that may arise out of or resulting from my child’s participation in this event. I also grant permission to Central Alabama Chrysalis to use photographs of my child on their website or other promotional materials, including social media.
Parent/Guardian Name: *

First NameLast Name
Relationship:
Please enter the relationship of Applicant
Parent/Guardian Cell Number:*
Parent/Guardian Email:
Please provide if you have an e-mail.
Parent/Guardian Signature
Enter Name as agreement to application
Date

MonthDayYear
Date
Medication Policy:

An adult Chrysalis representative will be designated as “nurse” for the weekend, and as such, will hold all medications for all candidates. All medications should be surrendered to the designated adult upon check-in for the weekend. The adult to whom the participant surrenders their medication has no medical training and will not calculate dosages. Participants should know when to take their medication(s) and will need to take initiative to retrieve their medication(s) on time. At the conclusion of the flight, it will be the participant’s responsibility to pick up any remaining medication(s). Because medical needs fluctuate, names of medications and exact dosages and frequencies/times should accompany all medication(s) upon arrival for the weekend. All over-the-counter (OTC) medications and prescription medications must be in original container with participant’s name. NOTE: Chrysalis candidates must be sponsored by someone who has attended Chrysalis, Emmaus, Journey, Cursillo, Tres Dias or other such weekends.
Sponsor's Name:*

First NameLast Name
Sponsor Cell Number:*
Sponsor's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Sponsor's Email:*
Please provide an e-mail.
Name of Church you attend:
Please enter Church attended
Are you in a Reunion Group?
Please answer Yes or No
When and Where was your Chrysalis/Walk to Emmaus?
Please answer Ex. Walk nnn - Camp Alamisco
Chrysalis Application
As Sponsor you agree to:

As Sponsor, you agree to: 1) clearly explain Chrysalis to the candidate 2) provide transportation to and from the Flight 3) attend Sponsors’ Hour and pray for your candidate 4) attend Candlelight and Closing 5) obtain necessary agape correspondence for your candidate 6) explain Reunion Groups and assist your candidate in getting into a Reunion Group 7) assist your candidate in participating in future Chrysalis and/or Emmaus events Sponsors are asked to read the following statement carefully and to give it their prayerful consideration: Chrysalis is a method of Christian renewal in the Church. Individuals recommended for Chrysalis should be those with an active desire to deepen their faith and understanding of God’s love and to become closer to Christ in their daily lives and in their discipleship. Chrysalis is NOT a weekend retreat or cure-all. Why do you feel your candidate would benefit from Chrysalis? Please include any pertinent information about the candidate that may help the Chrysalis team to meet their needs. Comments about the candidate’s home situation, personality, leadership ability and especially any problem areas would be of great assistance and will be kept confidential.
Sponsor Signature:*
Sponsor's Sign Agreement
Date Signed by Applicant*

MonthDayYear
Please select date.
Should be Empty:

Central Alabama Chrysalis Application

1. TO BE COMPLETED BY THE APPLICANT - PLEASE PRINT CLEARLY.

Medication Policy:

As Sponsor you agree to: