Chrysalis North Georgia Chrysalis Application

This is an application only. All required fields (the ones with the red "*" by them) must be completed for the application to be considered for acceptance.
Submission of this application is not a guarantee that the candidate will be able to attend the weekend.

Please select which Chrysalis / Young Adult Chrysalis(YAC) weekend your candidate wishes to attend, complete the form, and click on the submit button at the end of the form.

Remember, Chrysalis is for candidates who are ages 15-18 and have completed ninth grade. YAC is for candidates who are ages 18-24 and must be out of high school.

For Chrysalis application help, contact Garry Smithwick, Chrysalis registration, at (770) 737-4686, E-mail registration@northgachrysalis.com, or AOL instant messaging "GarrySmithwick".

Instructions: Complete all required fields and click the submit button at the end of the application form.

 
Submitter's Email * ...... Submitter's Name *
 
Weekend? * *** Please select a weekend from the list ***
 
Applicant Information
First Name * ...... Last Name *
Name Tag * ( First name as you wish it to appear on your name tag )
Gender * Female    Male   
Age * ...... Birthday * mm/dd/yy
E-Mail Addr * ( E-mail address of the candidate )
Phone No. * ...... Alternate Phone
IM ID AOL    MSN    Other   
Street Addr *
City * ...... State * ...... Zip *
Your Church *
Your School * ...... Current Grade * Freshman    Sophomore    Junior    Senior    Not In School   
HS Grad? * Yes    No    ... ( Will you be a high school graduate before the Chrysalis/YAC weekend starts? )
T-Shirt Size * Small    Medium    Large    X-Large    XX-Large    XXX-Large   
Why do you want to attend Chrysalis? *
What church activities are you involved in? *
Sponsor Explained? * Yes    No    ... ( Has your sponsor explained Chrysalis and the follow-up program of Reunion Groups and Hoots? )
Do you have any allergies? * Yes    No    ...... If Yes, list details
Will you be taking any medications? * Yes    No    ...... If Yes, list details
Do you have any special diet needs? * Yes    No    ...... If Yes, list details
 
Sponsor Information
First Name * ......Last Name *
Weekend Attended
E-Mail Addr *
Phone No. * ...... Alternate Phone
Street Addr *
City * ...... State * ...... Zip *
Church *
Relationship
to Applicant * 		Parent    Other Relative    Pastor    Youth Pastor/Director    Friend    Other   
Age 18+? * Yes    No    ... ( If sponsor is under 18, an adult co-sponsor is required)
Payment Type? * Check    Paypal   
Payment Amount * $25    $75    Other   
Co-Sponsor Information
First Name ...... Last Name
Weekend Attended
E-Mail Addr
Phone No. ...... Alternate Phone
Street Addr
City ...... State ...... Zip
Church
Age 18+? Yes    No   
 
Sponsor Questions
Sendoff? * Yes    No    ... ( Will you bring your applicant to Sendoff? )
Candlelight? * Yes    No    ... ( Will you attend candlelight? )
Closing? * Yes    No    ... ( Will you attend Closing?)
Pray? * Yes    No    ... ( Will you pray for your applicant? )
Hoot? * Yes    No    ... ( Will you bring your applicant to the first Hoot following the weekedn? )
Reunion Group? * Yes    No    ... ( Will you help your applicant find or establish a Reunion Group? )
Backup? Yes    No    ... (If you answered no to any of the above questions, will someone else fulfill these responsibilities? )
Did you pay via PayPal? * Yes    No   
Why are you recommending this applicant? *
 
Pastor Information
First Name * ...... Last Name *
Church *
E-Mail Addr *
Phone No. *
 
Additional Information
Use this area for any information which you feel we should know about your applicant.
 

Form Version: 20071219