CHRYSALIS APPLICATION

CHRYSALIS APPLICATION
Flight #
Date

MonthDayYear
Date
SECTION A: CANDIDATE INFORMATION
Name*

First NameLast Name
Name for Name Tag:
Male Female*

MaleFemale
DOB:*

MonthDayYear
Date
Age:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Candidate Email address:*
example@example.com
Church Name and the denomination presently attending:
School:
Grade level:
Has Chrysalis been fully explained to you?*

YesNo
Has Post Flight follow-up been explained to you?*

YesNo
If you are 18 years old at the time of the Flight, a background check is required. An email will be sent to you from the registrar for your authorization.
SECTION B: COVENANT OF CONDUCT
(1) The daily schedule will be followed at all times by participants. (2) No alcohol. (3) No illegal drugs. (4) No tobacco. (5) No inappropriate sexual behavior. (6) No willful destruction or abuse of property. Cost of repairs will be paid by those responsible for damage. (7) ALL medication will be listed with the designated adult. (8) Fireworks, firearms, skateboards, cell phones, cameras, or other electronics; and any other items that may interfere with the purpose of the event are not allowed. (9) Misuse of snack food, which includes the ordering or delivery of food items, is not allowed. (10) No one may leave the site of the event. Cars brought by youth are to be parked and not moved until the end of the event. (11) Total cost will be paid by each applicant/candidate regardless of the amount of time spent at the event.

Violation of Points 2-10 will result in the immediate expulsion of the participant from the event, and parents and pastors will be called.

I have read the COVENANT OF CONDUCT, and I agree to abide by all rules described therein.
Candidate's Signature:*

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Date:

MonthDayYear
Date
Page 1 of 5

SECTION F: SPONSOR'S SECTION
Sponsor's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Work Phone
Cell Phone
Email address:*
example@example.com
I have known the applicant for (yrs/months):
Chrysalis FLIGHT retreats are designed to deepen the relationship young men and women have with Christ. It is a time of self-discovery and spiritual centering. Sponsors should consider carefully whether their candidate has the maturity to truly benefit from the Chrysalis event. Candidates for Chrysalis should understand the nature of the weekend and be willing to engage in the discussions and self-reflection necessary to make Chrysalis a meaningful experience. Every sponsor should reflect upon his or her motivation for wanting to sponsor a young person and make sure it is consistent with the purpose of Chrysalis. Some examples of mistaken purpose include: “to get all my friends to go"; to have a full weekend; to reproduce one's own religious experience in others; to "fix" a young person's problems or crisis. After prayerful consideration, I would like to propose that this applicant/candidate, who has been attending church, as a candidate for the Chrysalis event.

I have known this candidate for the time indicated above and I think this is a good time for this candidate to attend a Chrysalis. I understand that my responsibilities as a sponsor include: prayer for my candidate leading up to and during the event, as well as participation in the sponsor's events during the weekend, and any other duties outlined to me as a sponsor. I will make every effort to fully participate in the Chrysalis event for my candidate.
Sponsor's Signature:

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Date:

MonthDayYear
Date
SECTION G: CHURCH LEADER, PASTOR, OR YOUTH DIRECTOR SECTION (if applicable)
I understand the purpose of the Chrysalis weekend and agree that this candidate is spiritually and emotionally mature enough to benefit from the Chrysalis experience at this time.
Name:
Church:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Email address:
example@example.com
Signature:

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Date:

MonthDayYear
Date
Check should be made payable in full and mailed to:
Brazos Valley Emmaus Community
ATTN: Chrysalis
P.O. Box 10491
College Station, Texas 77845

You may also pay online:
https://tithe.ly/give?c=6764499
Page 3 of 5

BRAZOS VALLEY EMMAUS CHRYSALIS APPLICATION Medicine Dispensing Form
Texas Department of Health Laws require that all medication, prescription or non-prescription drugs, will be held at the Camp First Aid Station and administered by Camp-Approved Medical Personnel, who are on-duty 24 hours a day.
Parent / Guardian: (please check one): Permission will / will not be allowed for over-the counter medicines to be dispensed to the above-named Minor.*

willwill not
Exceptions are:
(Example: cough drop, antacid, band-aid, acetaminophen, ibuprofen, etc.)
If you need to send medication to camp, please put it, along with THIS completed form in a zip-lock bag. Medication and the form will be turned over to the Camp-Approved Medical Personnel at the time of check-in.
REMEMBER. PLACE THIS FORM IN THE ZIPLOC BAG – ALONG WITH MEDICATION!
This medication belongs to:
Parent Name:
Cell Phone:
Alternate Phone:
Candidate's Sponsor Name & Phone
In the space below, please list any Medications, Dosage, Dosage Time(s) and any Special Instructions:
If medication is only to be administered "as needed" please indicate the circumstances in which to administer the medication:
Page 4 of 5

Chrysalis Butterfly Application Instructions
HAS THE CHRYSALIS FLIGHT BEEN EXPLAINED TO YOU? Make sure you are fully aware of what the Chrysalis Flight is all about. If you have a question, please ask your sponsor for more information. Your sponsor should not sign this form until he/she has explained Chrysalis and its follow-up to you. Check out the Chrysalis tab at https://bvemmaus.org/chrysalis
INFORMATION ON SPECIAL NEEDS: It is important to know if you have any special needs or challenges. It is rare that any such need cannot be met. It is helpful to know your needs in advance so we can make your Flight a fulfilling experience for you. Only those responsible to meet your needs will have this information.
INFORMATION REGARDING YOUR CHURCH MEMBERSHIP: Chrysalis is not intended to make disciples but rather strengthen those who are already disciples. Teens accepted for a Chrysalis Flight are expected to be ACTIVE members of a CHRISTIAN congregation. ALL EXCEPTIONS TO THIS POLICY will be reviewed by the Community Spiritual Director.
SIGNATURES REQUIRED ON THE FORM: All required signatures must be on the forms before being submitted. They are: Teen, Parent, Sponsor and Pastor (see above).
IT IS THE RESPONSIBILITY OF THE SPONSOR TO SEE THAT THESE SIGNATURES ARE ALL PRESENT!
1. YOUR SIGNATURE - This is your commitment to accept God's invitation to attend the Flight. The form must be signed by you personally. You agree to abide by the Code of Conduct of the Flight.
2. YOUR CHURCH LEADER, PASTOR or YOUTH DIRECTOR SIGNATURE.
3. YOUR PARENT'S SIGNATURE - Giving permission for your participation in a Chrysalis Flight.
4. YOUR SPONSOR SIGNATURE - This is your sponsor's commitment to both you and to the Chrysalis Community, that he/ she is willing to help you prepare for your Flight, care for your family while you are away, and help you become more active in service after the Flight. This signature emphasizes the great importance the Chrysalis Flight places on your sponsor.
Page 5 of 5
Should be Empty:

CHRYSALIS APPLICATION

SECTION A: CANDIDATE INFORMATION

SECTION B: COVENANT OF CONDUCT

SECTION C: MEDICAL INFORMATION

SECTION D: INSURANCE INFORMATION

SECTION E: PARENT/GUARDIAN INFORMATION AND SIGNATURE

SECTION F: SPONSOR'S SECTION

SECTION G: CHURCH LEADER, PASTOR, OR YOUTH DIRECTOR SECTION (if applicable)

BRAZOS VALLEY EMMAUS CHRYSALIS APPLICATION Medicine Dispensing Form

Chrysalis Butterfly Application Instructions