Noahs of Ark –Chrysalis/Journey

Application to attend Flight

TO BE COMPLETED BY THE CANDIDATE

CHRYSALIS IS OPENED TO YOUNG ADULTS -AGES 15 THRU 18 OR GRADUATING SENIORS

JOURNEY IS OPENED TO YOUNG ADULTS – AGES 18 (GRADUATED) TO 24 YEAR OLDS

SPONSOR’S NAME:Return to:Noahs of Ark Emmaus - Registrar

144 Apple Blossom Circle

______Hot Springs, AR 71913

Personal Information (Please Print)

Name:______Address:______

City:______State:____ Zip:______Primary Phone:______

Email: ______T-shirt size ______

Birth Date:______Age:______Gender:____M ___FLast Grade Completed: ______Year:______

Name of School/College:______Name wished on name tag:______

Do you require special meals?_____Y ____NIf yes, explain:______

Please describe any health or physical complications we should know about: ______

______

Special medications: ____Y _____N If yes, please list medicine, dosage and when required take on back of form.

Getting To Know You (Please Print)

Church Attending:______Pastor’s Name: ______

Youth Leader:______Church Phone: ______

In what religious/youth activities or community organizations are you active: ______

______

Do you see yourself as: (Check One):

_____”Shy/Quiet” _____”Moderately Talkative” _____”Always have something to say”

Are you currently employed? If yes, what do you do?______

Briefly state why you wish to be involved in a Chrysalis Weekend: ______

______

Please complete ALL the information above so we may make arrangements for your Chrysalis Weekend. We request this information only as an attempt to get to know you better. This information is not intended to prevent your involvement in Chrysalis. Keep in mind that the purpose of Chrysalis is to strengthen your faith and the local church. PLEASE NOTE: ALL CANDIDATES AND TEAM MEMBERS WILL NOT BE ALLOWED TO SMOKE OR USE TOBACCO PRODUCTS, ILLEGAL DRUGS, OR ALCOHOL DURING ANY CHRYSALIS FUNCTION.

**RESERVATIONS CANNOT BE ACCEPTED WITHOUT THIS FORM BEING NOTARIZED**

Please Circle Your Preferred Flight
Boys Flight 26 – January 17-20, 2014 / Girls Flight 26 – January 17-20, 2014
Boys Flight 27 – Summer 2014 (TBA) / Girls Flight 27 – Summer 2014 (TBA)
Boys Flight 28 – January 16-19, 2015 / Girls Flight 28 – January 16-19, 2015

<Continued on the back>

MEDICAL AUTHORIZATION

I am the parent/guardian of ______who has my permission to

attendthe Chrysalis weekend beginning on ______and ending on ______.

During this timeI may be reached at ______

(address and phone numbers)

Please list any allergies your son/daughter may have ______

Date of last tetanus injection ______Is he/she taking any special medication?______

If so, please send medicine in original prescription container, labeled with instructions and contents.

Doctor’s name ______Phone number ______

I understand that my son/daughter will be in the care of Chrysalis adult staff members. In case of emergency and I cannot be readily contacted, I hereby authorize any medical treatment that may be necessary to be administered to my child. I shall be responsible for the cost of such treatment.

Parent/Guardian Signature ______Date:______

Subscribed and sworn before me, a notary public in ______County, in the state of ______. This the ______day of ______, 20____.

Signature of Notary Public______

My commission expires on ______

I, ______, certify I am 18 years of age.

Signature: ______Date: ______

ATTENTION: Please enclose $75 per person with this request. This is the full cost of the weekend. Make checks payable to “Noahs of Ark - Chrysalis”. You and your sponsor will receive confirmation of acceptance by email as well as a list of necessary items to bring.

Medication:

Medication Name / Dosage / Time Needed