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

Living Arrangements
Who does the candidate live with?*

MotherFatherOther

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?*

Parental Consent and Liability Release Form
To whom it may concern:
The undersigned does hereby give permission for my child: {candidateName} (“Participant”), to attend and participate in the Cornerstone Chrysalis Weekend during the period of {PreferredWeekend} (or as extended by necessity) (hereinafter, the “Weekend”).

Liability Release: In consideration of the Cornerstone Chrysalis and Louisville Emmaus Community Boards, Agents and Representatives allowing the Participant to participate in the Weekend, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless the Cornerstone Chrysalis and Emmaus Communities, their Boards, Board Members, its directors, employees, volunteers and agents (collectively herein the “Chrysalis Community”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the Weekend. We (I) the parent(s) or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in the Weekend ministry activities, including participating in the Lord’s Supper.

Furthermore, we (I) [and on behalf of our (my) minor Participant(s)] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said Chrysalis Community to furnish any necessary transportation, food and lodging for this Participant. The undersigned further hereby agree to hold harmless and indemnify said Chrysalis Community for any liability sustained by the Chrysalis Community as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

Medical Treatment Release: We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

Early Return Home Policy: Should it be necessary for our (my) child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

Transportation Permission: The undersigned does also hereby give permission for our (my) youth to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in activities sponsored by the Chrysalis Community. My child/youth and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation unless medically impracticable.

Prescription Medication, Drugs, Tobacco & Alcohol: No drugs of any kind, tobacco or alcohol are permitted to be brought to the Weekend or taken or used during the Weekend by any Participant unless prior arrangements are made by the undersigned with the Chrysalis Community. With regard to the use of prescription medication, the undersigned understands and agrees that it is the UNDERSGINED PARENT/LEGAL GUARDIAN’S responsibility to see that any necessary prescription medication is timely administered to a participant. The undersigned understands that the Participant will not have regular access to a clock/watch during the Weekend. Therefore, all prescription medication must be brought to the Weekend in a clear plastic bag, clearly labeled with the Participant’s name, parent/legal guardian names, and phone numbers. The bag should also include a written time schedule detailing when the Participant shall be allowed access to his/her prescription medicine bag so that the Participant may administer his/her own medication. The Participant will be notified of medication times according to the schedule provided by the Undersigned. The Undersigned understands that he/she may personally come to the Weekend facility at the appropriate times during the Weekend to ensure that prescription medication is taken appropriately. The undersigned further agrees and understands that the Chrysalis Community WILL NOT ADMINISTER ANY PRESCRIPTION MEDICATION TO ANY CHILD AT ANY TIME and assumes no liability and/or risks associated with such.

Photographic Permission: I also give permission for videos or pictures of my child that may be taken during the Weekend to be shown in Chrysalis Community publications, displays and presentations.
Silver Heights Camp Waiver
The undersigned does hereby give permission for our (my) child (participant/camper), to attend and participate in all Silver Heights Camp ministry activities, events and retreats and to travel with a Silver Heights Camp & Retreat Center approved adult via a vehicle to the trip location and back.

Liability Release: In consideration of Silver Heights Camp & Retreat Center allowing the participant to participate in youth
activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless SilverHeights Camp & Retreat Center, its directors, employees, volunteers, and agents (collectively herein the “camp”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant while involved in camp activities.

We (I) the parent(s) or legal guardian(s) of this participant hereby grant our (my) permission for the participant to participate fully in youth ministry activities, including trips away from the camp premises. Further, authorization and permission are hereby given to said camp to furnish any necessary transportation (within the limitations of camp insurance and the law), food and lodging for this participant. The undersigned further hereby agrees to hold harmless and
indemnify said camp for any liability sustained by said camp as the result of the negligent, willful or
intentional acts of said camper, including expenses incurred attendant thereto.

Transportation Permission:
The undersigned does also hereby give permission for our (my) participant to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in activities sponsored by Silver Heights Camp. My camper and I understand that seat belts shall be worn on non-bus vehicles at all time during transportation.

Medical Treatment Permission: We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all cost and expense incurred in connection with such medical and dental
services rendered to the aforementioned child or youth pursuant to this authorization.
Parent/Guardian Name*

First NameLast Name
Signature*

Clear
Signature Date*

MonthDayYear
Date

Should be Empty:

Candidate Application

Candidate Information

Sponsor Information

Candidate Information

Background Check Information

Parent/Guardian Information

Emergency & Medical Information

Parental Consent and Liability Release Form

Silver Heights Camp Waiver