Hi-Sky Chrysalis Community

Flights – Ages 15 – 19                                                                                                                    Journeys – Ages 18 – 24

Request for Reservation

Please print and fill in ALL blanks in BLACK ink                                          Flight/Journey choice:                                        

To be filled out by candidate 

NAME:                                                                                                 CIRCLE ONE:           Male             Female

ADDRESS:                                                                                            BIRTHDAY:                                                       

(Permanent)                                                                                                                

CITY, STATE, ZIP:                                                                                YOUR PHONE:                                                  

CIRCLE ONE:               Married               Single.                                      # of children:                                                    

NAME FOR YOUR NAMETAG:                                                                                                                                         

SCHOOL NOW ATTENDING:                                                                 CIRCLE ONE:        Freshman    Soph    Jr    Sr

CHURCH:                                                                                                                                                                       

The following information pertains to your parents or spouse:

NAMES:                                                                                                HOME PHONE:                                                  

ADDRESS:                                                                                                                                                                    

Has the Chrysalis and the post-weekend follow up been explained to you?                              Yes             No

State briefly why you wish to be involved in Chrysalis and what you expect from it:

                                                                                                                                                                                     

                                                                                                                                                                                     

Please enclose $115 per person with this request for reservation.  This is the full cost to you for the weekend and is refundable up to seven (7) days before the Chrysalis.  Please make your check payable to Hi-Sky Emmaus.  In the event that you must cancel, please notify the Chrysalis registrar (see below).  Each person registering must be sponsored by someone who has already attended a Walk to Emmaus or Chrysalis.  If  the candidate is being sponsored by a youth, there must be an adult who co-sponsors.  If a partial scholarship is needed, please complete the scholarship request on the back of this form.  If you are receiving a scholarship from another source (eg:  your  church, your sponsor) please indicate that on the back.

YOUR SIGNATURE:                                                                               PRINT NAME:                                                   

PASTOR'S SIGNATURE:                                                                         PRINT NAME:                                                   

SPONSOR'S NAME:                                                                       

                                                                                                            SPONSOR

SPONSOR'S ADDRESS:                                                                          WALK/CHRYS ATTENDED:                                   

City, State, Zip                                                                                      CO-SPONSOR:                                                  

FOR OFFICE USE ONLY:
 Date received:  __________________________
Flight#  ________       ________       ________
Paid       ________        CK# __________
              ________        CK# __________

Scholarship request?      YES             NO
 Date granted    ___________________________
 
SPONSOR'S PHONE:                                                                     

PLEASE MAIL COMPLETED APPLICATION WITH CHECK TO:

                        Hi-Sky Chrysalis Registrar

                        PO Box 123

                        Midland, TX  79702

                        Attn:  Melissa Crooks

                        Phone: 522-1151

Applications MUST include a Pastor's signature and at least $50 prior to processing.

Please complete and have parent sign the health release on the back if you are under 18, otherwise, sign for yourself.


  HEALTH RELEASE FORM

To be completed by Parent, Guardian, or Self if over 18

                                                                                                  has my/our permission to attend the Chrysalis weekend.  In the event of an emergency, and if I/we cannot be reached by telephone, the Chrysalis staff has my/our permission to gain the services of licensed medical professionals to provide the care deemed necessary, including anesthesia, for my/my child's well being, the cost for which I am responsible.

Parent, Guardian, or Self

Signature:                                                                                            Phone:                                                              

If the above cannot be reached, please call:

                                                                                                            Phone:                                                              

Please list all allergies, medications being taken, medical problems, special diets, physical handicaps, or other pertinent information that may affect your attendance and well being at Chrysalis

Explain:                                                                                                                                                                       

                                                                                                                                                                                     

                                                                                                                                                                                     

                                                                                                                                                                                     

                                                                                                                                                                                     

                                                                                                                                                                                     

                                                                                                                                                                                     

Social Security #:                                                                        

Insurance Company:                                                                              Policy#:                                                           

 

SCHOLARSHIP REQUEST

 No one will ever be prevented from attending a Chrysalis sponsored by the Hi-Sky Emmaus Community for financial reasons.  However, you and/or your sponsor are urged to pay some portion of the Flight fee.  Partial scholarships from the Hi-Sky Chrysalis Community are available for up to $65.   If you need such assistance, please provide a brief statement explaining the circumstances surrounding the need and the amount requested.