Picture of Chrysalis Butterfly

Application Form

Please print and mail your application and consent form or fill out the online application below. If you are filling out the online application, you may email your Consent Form to the Registrar if you chose. Your application process will not be complete until the Consent Form is received and the Registrar has confirmed your completed application. Please make sure all fields with a * are completed before submitting your application.

  Mail-In Application & Consent Form (PDF) Download Adobe Reader
  Consent Form for Online Application (PDF)

Online Registration Application

  Chrysalis Event *


Flight: Age 15 or 10th Grade through summer after Senior Year
Journey: Summer after Senior year through age 22
* As of 2014, Flights and Journeys have been combined to be held on the same weekend.

Applicant Information

  Name *

First

Last
  Mailing Address *
Street Address
City
State
Postal / Zip Code

  Email *
  Home Phone

-
- Please include at least one phone number.
  Cell Phone

-
-
  Date of Birth *

/
/
  Sex *
 Male 
 Female 
  T-Shirt Size *

Emergency Contact Information

  Emergency Contact *
Must be a parent or
guardian if under 18.

First

Last
  Relation *
  Cell Phone *

-
-

Other Information

  High School / College Name
  Education Level *
  Church Name
  Please list your High School, College, and/or Church activities.
  Do you have food allergies or require special meals?
If yes, please explain.
If not, type "None".
*
  Do you take any special medications?
If yes, please list the medications and when you take them.
If not, type "None".
*
  Is there anything you feel the weekend leaders need to know about you in order to meet your needs or serve you better?
  Briefly state why you wish to attend Chrysalis and what you expect from attending a Chrysalis weekend. *

Sponsor Information

  Sponsor Name *

First

Last
  Sponsor Mailing Address *
Street Address
City
State
Postal / Zip Code

  Sponsor Phone

-
- Please include at least one phone number.
  Sponsor Cell Phone

-
-
  Sponsor Other Phone

-
-
  Sponsor Email *

Consent & Payment Information

  Consent Form *
 I understand I must print and mail or email the Consent Form to the Registrar for my application to be complete. 
If we do not receive your Consent Form, we cannot guarantee you will be able to attend a Chrysalis weekend.
  Payment *
 I understand the registration fee to attend a Chrysalis weekend is $110.00. 
The registration fee is due at check-in prior to the Chrysalis weekend. Checks can be made out to Heart of Georgia Chrysalis.