Chrysalis Caterpillar Application – Cincinnati Emmaus Community

Participant's Information

Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Email

Phone

Would you like text notifications for events?

Yes

Date of birth

Gender

Male
Female

Marital status

Married
Single

T-Shirt size

School name

Grade

Church

Church Phone Number

Pastor's Name

First Last

Do you attend church services regularly?

Yes
No

Has Chrysalis been explained to you?

Yes
No

Why do you want to attend Chrysalis?

List family members who have attended Chrysalis or Emmaus:

Parent's Information

(If under the age of 18)

Parent's Name

First Last

Parent's Phone

Parent's Email

Sponsor's Information

Sponsor's Name

First Last

Sponsor's Email

Sponsor's Phone

Medical Information

Emergency Contact Name

First Last

Emergency Contact Phone Number

Primary Care Physician's Name

First Last

Physician's Phone Number

Preferred Hospital

Please list any allergies, including allergies to medications:

Will you be bringing any medications to the Flight?

Do you have any dietary restrictions or mobility needs?

In the unlikely event that medical intervention is necessary for the participant, every attempt will be made to contact the individual listed as the Emergency Contact. Only if that person cannot be reached in an emergency during the Chrysalis Flight for which permission has been granted for the participant to participate, I hereby give my permission to the Chrysalis Leadership Team to hospitalize at preferred hospital (or any hospital reasonably accessible), secure medical treatment and order an injection, anesthesia, or surgery for myself/minor child as deemed necessary. I understand that I am liable for any expenses incurred due to emergency treatment. I understand all reasonable safety precaustions will be taken always by the Greater Cincinnati Chrysalis Community and its agents during the Flight sponsored by the same. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Greater Cincinnati Emmaus and Chrysalis Community, its Board of Directors, its leaders, employees or volunteers liable for damages, losses, diseases, or injuries by the subject of this form.

Digital Signature (please type) of parent or participant if participant is 18 or older:*

First Last