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North Mississippi Chrysalis and Crossroads Team Application
Email address *
Name of Applicant *
Your answer
Date of Application *
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YYYY
Date of Birth *
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DD
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Your Original Chrysalis/Crossroads Flight Number or Emmaus Walk Number *
Your answer
Table Name *
Your answer
Gender *
Address *
Your answer
City *
Your answer
State *
Your answer
ZIP Code *
Your answer
Email Address *
Your answer
T-Shirt Size *
Cell Phone *
Your answer
Alternate Phone
Your answer
Class *
Special Interests
Responses to the following questions are necessary to meet the Safe Sanctuary standards of the Upper Room: Are you currently under investigation for a crim involving children or youth? *
Have you been accused or convicted of any incident involving youth or children? *
Have you been convicted of a felony involving a sexually related crime or offense? *
If any of the above questions are answered yes, you may be subject to a background check. *
Please list any medical allergies, medications currently taking, medical problems, special diet, or other pertinent information:
Your answer
Check the committees on which you have served
Chrysalis/Crossroads
Emmaus
Committee coordinator
Assistant Committee Coordinator (Floater)
Food Chair
Food Committee
Agape Chair
Agape Committee
Conference Room Clean-Up
Prayer Room Committee
Registration and Booklet
Literature and Supplies
Worship Chair
Worship Committee
Check the conference room positions in which you have served:
Chrysalis / Crossroads
Emmaus
Lay Director
Assistant Lay Director
Spiritual Director
Assistant Spiritual Director
Table Leader
Assistant Table Leader
Board Advisor
Music Team
Check the Chrysalis talks you have given
Check the Emmaus talks you have given:
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