Cross Bayou Application

 FORM, ALONG WITH PAYMENT, MUST BE RETURNED TO YOUR SPONSOR

Name    Nametag name  
Address   City         State    Zip
School Date of graduation T-Shirt size
Male     Female
PARENT / GUARDIAN
Name(s)  
Phone (H)  Alternate Number

IN CASE OF EMERGENCY, IF PARENT / GUARDIAN IS UNABLE TO BE REACHED PLEASE
Contact

NAME                                               PHONE                             RELATIONSHIP

yes no - Have you been informed to expect NO outside contact during the weekend, except in an emergency?

yes no - Has it been explained to you that all flights are SMOKE FREE events?

I, the parent/guardian, give my son/daughter permission to attend this Chrysalis Three Day Weekend.


Parent / Guardian Signature                                 Date



Pastor / Youth Pastor - Director Signature           Date



Participant's Signature                                     Date

NOTARY REQUIRED IF APPLICANT IS UNDER 18
Subscribed and sworn to before me, (Name of Notary)

A Notary Public, in Parish/County, Louisiana/Texas

the day of , 20

Signature of Notary Public

My Commission expires


Cross Bayou Application

MEDICAL AUTHORIZATION
REQUIRED BY ALL APPLICANTS REGARDLESS OF AGE

I am the parent/guardian of

During the event I can be reached at
Please give an telephone number and alternate number                               

Doctor's NamePhone Number

Insurance ProviderPhone Number
PLEASE PROVIDE PHOTO COPY OF INSURANCE CARD, FRONT AND BACK

Participant's SSN# (This is needed in the case of emergency treatment)

Date of last Tetanus shot Are there any medications to be taken during the weekend? yes no
List Medication

List Allergies    

Explain any special dietary requirements


Describe any health accommodations that might be needed.  This includes physical, mental, spiritual or
emotional.  All information is confidential








COST OF FLIGHT IS $70.00.

Make all checks payable to Cross Bayou Chrysalis


Cross Bayou Application

COST OF FLIGHT IS $70.00.

Make all checks payable to Cross Bayou Chrysalis

Your Name Phone Number    
Address   City         State   Zip  
 Email Address  Your church    
What three day weekend did you attend?      When   Where?    Walk / Flight #     

yes no - Does your candidate have the physical and mental health needed for Chrysalis Flight weekend?
yes no - Have you informed the candidate that they should expect to have NO outside contact during the weekend, except in case of emergency?  
 yes  no - Have you explained that all flights are SMOKE FREE events? 
 yes no - Will you personally bring the candidate to the site?
 yes no - Are you praying for your Candidate?
 yes no - style="font-size: 12pt">Help your candidate get into a reunion group?
 yes no - Have you explained the follow up meeting?
As a sponsor, are you willing to say "YES" to Christ - to fulfill your responsibilities so that His grace and love are revealed through your actions? 

 
CONFIDENTIAL INFORMATION FOR THE LAY AND / OR SPIRITUAL DIRECTOR

Why did you sponsor this person for a Chrysalis Flight?  

If possible, describe your candidate's personality, spiritual growth, etc. to asist the team in seating and room assignments.


 

Mail Completed forms and fees to:
Bonnie Keene
110 Peaceful Bay
Homer, La. 71040