Caterpillar Application Flight #44
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Hello, thank you for considering being a caterpillar on an upcoming Chrysalis flight. Please fill out the information below and see that your sponsor fills out their form as well. Then, please mail your $30.00 registration deposit to our registrar at 2006 Baird Avenue, Portsmouth OH, 45662. This is to be applied to the total $60.00 cost of the flight. This deposit is nonrefundable. Please make your check payable to SOUTHERN OHIO CHRYSALIS. Fly with Christ!
Full Name (First and Last) *
Name Tag
Street Address *
City *
State *
Zip Code *
Email *
Phone Number (no spaces) *
May we text you? *
Birth Date *
MM
/
DD
/
YYYY
Current Age *
Gender *
Shirt Size *
High School or College (if applicable) *
Grade *
Church Name & City
Why do you wish to participate in a Chrysalis flight? *
Do you certify this information is correct? *
Required
Emergency Contact Information
Please provide us some information regarding an emergency contact in case of serious situation.
In the event of an emergency, if your emergency contact cannot be reached by the number provided, Chrysalis staff has permission to secure the services of licensed medical professionals to provide the care necessary, including anesthesia. *
What is your emergency contact's name? *
What is your emergency contact's phone number? *
Parent/Guardian Information
Please be sure that the information above is that of the caterpillar, and the information below is that of a parent of guardian.
Name *
Parent Email
Parent Address (if differs from child)
Parent Phone Number
Do you agree to allow your child to attend the Chrysalis Weekend? In the event of an emergency, if you cannot be reached by the number provided, Chrysalis staff has permission to secure the services of licensed medical professionals to provide the care necessary, including anesthesia. *
Please list any medical allergies, medications being taken, special diets, medical problems, or other pertinent information regarding the applicant.
By signing this application, you are giving permission to Southern Ohio Chrysalis to list your child's name on the Southern Ohio Chrysalis website for prayer support purposes.
Please mail a $30.00 registration deposit to our registrar at 2006 Baird Avenue, Portsmouth OH, 45662. This is to be applied to the total $60.00 cost of the flight. This deposit is nonrefundable. Please make your check payable to SOUTHERN OHIO CHRYSALIS.
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