test

Chrysalis Caterpillar Application

  • Participant's Information

  • Parent's Information

    (If under the age of 18)
  • Sponsor's Information

  • Medical Information

  • 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.