Caterpillar Application Boys Flight #49

Caterpillar Application Boys Flight #50

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 NameLast 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.
Your Street Address*
Your City*
Your State*

OhioKentuckyWest VirginiaIndianaOther
Your Zip Code*
Your Birthday*

MonthDayYear
Date
Your Current Age*
Your Gender*

MaleFemale
Your Shirt Size*

SmallMediumLargeX-LargeXX-LargeXXX-Large
Your High School or College (if applicable)
Your Grade*

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

Clear
Sponsor Information

Please talk with your sponsor and discuss the information listed below. Be sure to make sure you both are aware of how you will be brought to Chrysalis as well as how you will be brought home from Chrysalis.
Sponsor's Name*
Full Name
Sponsor's Email*
example@example.com
Sponsor's Phone Number*
Please enter a valid phone number.
What weekend did your sponsor attend initially?

ChrysalisEmmausNoneOther
Parent/Guardian/Emergency Information

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

First NameLast Name
What is your Parent/Guardian/Emergency Contact's phone number?*
Please enter a valid phone number.
Parent/Guardian/Emergency Contact Email*
example@example.com
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. The emergency number to reach us at Chrysalis is (740) 821-4438. 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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Caterpillar Application Boys Flight #50