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North Mississippi Chrysalis and Crossroads Team Application
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Email *
Name of Applicant *
Date of Application *
Date of Birth *
Your Original Chrysalis/Crossroads Flight Number or Emmaus Walk Number *
Table Name *
Gender *
Address *
City *
State *
ZIP Code *
Email Address *
T-Shirt Size *
Cell Phone *
Alternate Phone
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:
Check the committees on which you have served
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
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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