Chrysalis—Candidate Application

Candidate Application

To be filled out by the candidate and the candidate's parent(s)/guardian(s).
Sender Name
Sender Email
example@example.com
Candidate Information
Candidate Full Name (OLD--DO NOT USE)*

FirstLastSuffix
Candidate Name*
First & Last Name
Candidate Email Address*
Sponsor Information
Sponsor Full Name (OLD--DO NOT USE)*

FirstLastSuffix
Sponsor Name*
First & Last Name
Sponsor Email Address*
**Candidate Name and Sponsor Name cannot be the same!
**Candidate Email Address and Sponsor Email Address cannot be the same!

Candidate Information
Full Name*

FirstLastSuffix
What name would you like on your name tag?*
If you go by your First Name, enter it here. Otherwise, enter the name you go by.
Date of Birth*

MonthDayYear
How old will you be by the end of this weekend?*
Gender*
Mailing Address*

Street Address

Street Address (Line 2)

CityState

Zip Code
Phone Number*

Area CodePhone Number
School Name*
Grade*

SophomoreJuniorSenior
What activities or clubs are you involved in? What interests you?
Ex: Basketball team, marching band, photography, reading novels
Church Name*
Youth Pastor (or Pastor) Name*
Preferred Weekend Date*
Preferred Chrysalis Weekend Date

MonthDayYear
Why do you want to be involved in Chrysalis? What do you expect from it?*

Background Check Information
Due to the fact that you will be 18 years old by the end of this weekend, we are required to run a background check on you. This information below will not be used to determine your acceptance for the weekend and will only be used for verification purposes through the background check service, ProtectMyMinistry.
Social Security Number*
Enter numbers only. No spaces or hyphens.
*Social Security Number must contain 9 digits total.
First Name*
Your legal first name
Middle Name*
Your legal middle name
Last Name*
Your legal last name
Have you lived at the address you provided for more than 5 years?*
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Ethnicity*

Parent/Guardian Information

To be filled out by the candidate's parent(s) or guardian(s). List only individuals who may be contacted in case of emergency and may assume care of the candidate.

Mother/Guardian 1
Mother/Guardian 1 Full Name*

FirstLast
Primary Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Email Address
By entering your email above, you give permission to be contacted by email.
Place of Employment

Father/Guardian 2
Father/Guardian 1 Full Name*

FirstLast
Primary Phone Number*

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Email Address
By entering your email above, you give permission to be contacted by email.
Place of Employment

Emergency & Medical Information

To be filled out by the candidate's parent(s) or guardian(s).
Insurance Name*
Name of Responsible Person*
Policy Number*
Group Number*
Is the candidate taking any medications (prescription or over-the-counter)?*
All medications must be turned in at the start of the weekend to be administered by a team member.
Please list all medications the candidate is taking.*
Include medication name, dosage, frequency taken and any other pertinent information.
Does the candidate have any dietary restrictions and/or allergies?*
Example: vegetarian, gluten allergy, nut allergy, etc.
Please list all dietary restrictions and/or allergies that apply to the candidate.*
List any information an adult team member should know regarding the candidate's physical or mental disability in the event of an emergency:
If the candidate does not have any physical or mental disabilities, leave field blank.
List the candidate's drug allergies:
If the candidate does not have any drug allergies, leave field blank.
Do you give permission for a member of the team to administer Tylenol (Acetaminophen), Motrin (Ibuprofen) or TUMS to your child while on the weekend?*
Should be Empty:

Candidate Application