Tidewater Chrysalis Application
Mail form to: Tidewater Chrysalis PO Box 8534, VA Beach, VA 23450
Email: tidewaterchrysalisregistrar@gmail.com
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Email *
Full Name *
Name for your Nametag
Date of Birth *
Gender *
Address: Street *
City *
State *
Zip Code *
Home Phone
Cell Phone *
School you attend
Church you attend *
Pastor Name
Has the Chrysalis Weekend and the follow-up gatherings been explained to you?
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Do you play an instrument or sing
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If instrument, which ones
State briefly why you wish to participate in Chrysalis and what you expect from this weekend. *
Please list all medications *
Do you have any allergies or other medical conditions *
Do you have a special diet, please specify *
What is your shirt size? *
Participant E-Sign *
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