West Ohio Chrysalis Weekend Application
Welcome, future butterflies - we are so excited to have you! If you are a caterpillar for an upcoming Chrysalis weekend, please fill out this form and submit with your application fee as soon as possible. Please remind your sponsor to fill out their application as well, which can also be found on our website.
Which weekend would you like to attend?
Girls' Winter 2020 (January 18-20)
Boys' Winter 2020 (February 15-17)
Date of birth
(You MUST be between 15-24 years old by the start of the weekend)
Parent's Name (if you are under 18)
Permanent Street Address
City, State, and Zip Code
Adult T-shirt Size
Name of church you currently attend (if any)
Pastor's Name and Contact Information (if applicable)
Current School (high school, college, etc.)
Why do you wish to participate in Chrysalis?
Do any of the following apply to you?
I have medical allergies
I am taking medication
I have a special diet or food allergy
I have physical or mental health conditions
None of the above
If yes to any of the above, please explain:
I agree to being photographed or mentioned (first name and last initial only) in any Chrysalis community publishings, whether online or in print:
I hereby accept that all information above is accurate, and I acknowledge that I will need to pay the application fee within 10 business days (or at the start of the weekend, whichever comes first) of the submission of this form via mail or drop-off to Greene Street Church.
Fees can be mailed or dropped off to 415 W. Greene St, Piqua, OH 45356. If you are concerned about being able to pay the full fee, there are scholarships available. You or your sponsor can contact the treasurer, Sherry Heath, with any questions or concerns pertaining to submitting your fee in the time allotted once this form is completed.
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