Chrysalis Caterpillar Application Participant's InformationName First Last Address Street Address City State / Province / Region ZIP / Postal Code Email PhoneWould you like text notifications for events? Yes Date of birth Month Day Year Gender Male Female Marital status Married Single T-Shirt size Small Medium Large X-Large 2X-Large School name Grade Church Church Phone NumberPastor'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 PhoneParent's Email Sponsor's InformationSponsor's Name First Last Sponsor's Email Sponsor's PhoneMedical InformationEmergency Contact Name First Last Emergency Contact Phone NumberPrimary Care Physician's Name First Last Physician's Phone NumberPreferred 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 Δ