Chrysalis Weekend Applicant Form

Chrysalis Weekend Applicant Form

January 17-19, 2026
Name

First NameLast Name
Birthdate*
You are a:
You are a:
Name as you would like it on your name tag:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
T-shirt Size
Current School / completed year
School activities
If over 18, Safe Sanctuaries requires a background check. Please sign that you agree to having a background check run by Fellowship UMC. (A link will be sent and must be completed prior to the weekend.)
(Youth Only) Has the Chrysalis weekend been explained by your Parent/Guardian/Sponsor?
Have the follow-up Gatherings been explained to you?
State briefly why you would like to attend a Chrysalis weekend and what you hope to gain from it.
Pastoral Information
Name & Denomination of Church:
Pastor's Name:
Pastor's email:
Campus Minister (if applicable)
Sponsor Name

First NameLast Name
Sponsor email
example@example.com
Over the course of the Chrysalis Weekend, group pictures will be taken as well as some candid shots during dining and break times. By signing this application, you acknowledge pictures may be published on teh Nashville Chrysalis website. NO INFORMATION WILL BE SHRED. If you prefer NOT to have your photograph taken, please initial here.
Initial:
Medical and Parental Information
List allergies, medications being taken, medical problems, special diet or other pertinent information:
Emergency Contact (if youth parent cannot be reached) or Adult Emergency Contact:
Phone:
Youth 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 services of licensed medical professionals to provide the care necessary, including anesthesia, for my child's well being. We further do hereby release and discharge 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 or traveling to or from this event. (Sign/Date)*

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Chrysalis Weekend Applicant Form

Pastoral Information

Medical and Parental Information