Application

CANDIDATE APPLICATION

CHRYSALIS WEEKEND REQUESTED

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APPLICANT INFORMATION

MEDICAL/PHYSICAL INFORMATION

EMERGENCY CONTACT INFORMATION

COVENANT OF CONDUCT

All participants are asked to comply with the following:

• Please leave all cell phones, watches, and electronic devices at home

• No alcohol

• No illegal drugs

• No willful destruction or abuse of property

• No smoking/ tobacco

Candidate’s Pledge:
I promise that I will come to the Chrysalis Flight with a spirit of cooperation and abide by the rules and policies stated above. I understand that violation of any rules can result in being sent home.

I agree

PARENT/GUARDIAN CONSENT

Does the Parent/Guardian listed above give permission to the Chrysalis applicant to attend Chrysalis?

Yes

In the event of an emergency, and if the Parent/Guardian listed above cannot be reached by phone, does the Chrysalis staff have permission to secure the services of licensed medical professionals to provide the care necessary, including anesthesia, for the Chrysalis applicant's well being?

Yes

Fee Breakdown:

$40 Deposit
$100 Remaining
$140 Total

Please note that the $40 deposit is due for this Flight as soon as possible after both the Candidate and Mentor applications are sent (the remaining $100 can be paid at any point before or on the evening of the Flight). Checks/money orders should be made payable to SWVA Emmaus. In the event you must cancel, please notify the Registrar as soon as possible (using the contact info below) so that you may be rescheduled. In the event of cancellation, the deposit will be refunded and you will be notified by phone, mail, or email prior to the Flight date.

The payment should be sent to:

SWVA Chrysalis Registrar
Ronda Wickham
3400 Hemingway Road
Roanoke, VA 24014
Registrar Contact (opens new tab)

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Confirmed