Northern Kentucky Chrysalis Registration Form
All information (especially, social media) will only be used as a means of staying connected with participants after the weekend.
Applicant Name *
Your answer
Name for name tag *
Your answer
Gender *
Required
Age *
Your answer
Date of birth *
MM
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DD
/
YYYY
Applicant cell phone #
Your answer
Applicant home phone # *
Your answer
Street address *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
Applicant email address *
Your answer
Applicant t-shirt size *
Required
Applicant Twitter handle
Your answer
Applicant Instagram name
Your answer
Applicant Snapchat name
Your answer
Applicant Facebook name
Your answer
Parent/guardian names *
Your answer
Parent/guardian email address *
Your answer
Parent/guardian phone # *
Your answer
Home church *
Your answer
Denomination *
Your answer
Pastor's name *
Your answer
Pastor's email
Your answer
Please list a few religious and community activities in which you have participated. *
Your answer
Middle/High School Name *
Your answer
Graduation Date *
MM
/
DD
/
YYYY
Grade *
Your answer
Please list any school activities in which you have participated.
Your answer
Has Chrysalis been explained to you? *
Required
Has the follow-up meeting been explained to you? *
Required
Please explain why you want to participate and identify any expectations. *
Your answer
Sponsor's name *
Your answer
Sponsor's phone # *
Your answer
Sponsor's email *
Your answer
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