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.
Email address *
Which weekend would you like to attend? *
Full Name *
Your answer
Date of birth *
(You MUST be between 15-24 years old by the start of the weekend)
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DD
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Sponsor's Name *
Your answer
Parent's Name (if you are under 18)
Your answer
Permanent Street Address *
Your answer
City, State, and Zip Code *
Your answer
Phone Number *
Your answer
Adult T-shirt Size *
Name of church you currently attend (if any)
Your answer
Pastor's Name and Contact Information (if applicable)
Your answer
Current School (high school, college, etc.) *
Your answer
Why do you wish to participate in Chrysalis? *
Your answer
Do any of the following apply to you? *
Required
If yes to any of the above, please explain:
Your answer
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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