Heart of Carolina Chrysalis Flight Application by Masterpee


									     Heart of Carolina Chrysalis Flight Application
                            Boy’s Date: ________ Girl’s Date: ________

 To be completed by Youth
Full Name:______________________________ Birth Date:____________________________
Name you wish to be called:_______________ Gender:_______Current Grade:_________
Address:_________________________________ School:________________________________
State:________ Zip:________________________ E-Mail:_______________________________
Home Phone:_____________________________ IM/Text Address:______________________
Are you on a special diet?__________________ If yes, explain:________________________
Church, School, Community Activities:____________________________________________
Has Chrysalis been explained to You?________________The Follow-up?_______________
State briefly why you wish to participate in Chrysalis and what you expect from it:___
Please include a pre-registration deposit of $25 with this registration. This will be applied
toward your contribution of $125 which partially offsets the expenses of the Chrysalis Flight. This
deposit is not refundable. If the flight is full, then we will carry your name over to the next flight or your
deposit will be refunded. Make you check payable to: Heart of Carolina Chrysalis

Youth’s signature:
 To be completed by Parent or Guardian:
__________________________________ has my/our permission to attend Chrysalis. In the event of
an emergency, and if I/we cannot be reached by phone, the Chrysalis staff has permission to secure the
services of licensed medical professionals to provide the care necessary, including anesthesia, for my
child’s well being.

Please list any medical allergies, medications being taken, medical problems or other pertinent
Medical Insurance Company and Number:_______________________________________________
 To be completed by Sponsor

Address:__________________________________Home Phone:__________________________
City:_____________________________________Work Phone:__________________________
Where did you attend Chrysalis/Emmaus/Cursillo?_________________________________
When did you attend your originalChrysalis/Emmaus/Cursillo?______________________
Are you in a reunion group?_____________Have you been a sponsor before?___________
Why do you think this youth would benefit from Chrysalis?_________________________
     Are you willing to pray and sacrifice for your candidate?             ________
     Will you be responsible for getting your candidate to Chrysalis?      ________
    Will you be responsible for getting your candidate home?               ________
    Are you aware of the importance of minimal contact with your
    candidate during the Chrysalis Flight?                                 ________
     Have you explained the Hoots, Gatherings, and Reunion Groups?         ________
      Will you accompany your candidate to the Hoots and/or Gatherings?    ________
      Do you understand the responsibility of assisting your candidate
      in finding a Reunion Group?                                          ________
Does your candidate have a physical or mental health concern that should be
brought to the attention of the Directors?__________________________________________
Does your candidate have a fear of clowns?________________________________________
Please make any additional comments you believe may be helpful:___________________
Please return to: Herold & Shannon Rothrock
                  HOCC Registrar's
                  7609 Devere Court
                  Raleigh, NC 27613

         herold_rothrock@earthlink.net                   (919) 787-0179

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