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North MS Chrysalis and Crossroads Caterpillar Registration
Email address *
Caterpillar Name *
Your answer
Date of Application *
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What is the preferred weekend for attendance for Chrysalis or Crossroads? Chrysalis is for students who have completed 9th grade to 12th grade and Crossroads is for college age students.
Home Mailing Address (Street, City, State, and ZIP) *
Your answer
Cell Phone *
Your answer
Alternate Phone
Your answer
Email Address *
Your answer
Date of Birth *
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Gender *
T-Shirt Size *
Name to be put on your nametag: *
Your answer
Name and Town of your church *
Your answer
Demonination
Your answer
Pastor Name
Your answer
Religious or Community Organizations
Your answer
School you attend or work that you do *
Your answer
Grade in High School or Year in College: *
Your answer
School Address, City, State, and ZIP
Your answer
Has Chrysalis been explained to you?
Has the follow-up of Group Reunions and Gatherings been explained to you?
Briefly tell why you want to participate in Chrysalis and what you expect from it: *
Your answer
Youth Sponsor Name (if applicable)
Your answer
Youth Sponsor Address, City, State, and ZIP
Your answer
Youth Sponsor Phone Number
Your answer
Youth Sponsor Email Address
Your answer
Adult Sponsor Name (Required) *
Your answer
Adult Sponsor Address, City, State, ZIP *
Your answer
Adult Sponsor Phone Number *
Your answer
Adult Sponsor Email *
Your answer
Adult Sponsor: Where and When did you attend Emmaus or Chrysalis? *
Your answer
Parent / Guardian Name *
Your answer
Parent / Guardian Mailing Address, City, State, and ZIP *
Your answer
Parent / Guardian Phone Number *
Your answer
Other Emergency Contact Name and Number *
Your answer
Please list any medical allergies being taken, medical problems, special diet or other pertinent information.
Your answer
Have you sent in the pre-registration deposit of $25? If not, please mail to Sara Pollan, 6701 Pearidge Rd., Grenada, MS 38901 or pay on the website. Please write the name of the caterpillar on the memo line on a check made out to North Mississippi Chrysalis.
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