Flight(15-18Yearsold,Highschoolsophomore-Senior)Information

NortheastOhioChrysalis

Flight(15-18YearsOld,HighSchoolSophomore-Senior)Information

Candidate

Which flight will you attend at Camp Wanake in Beach City, OH

Boys – June 3-5___ Girls – June 10-12____

Name:NameonBadgeshouldread:

HomeAddress:City/State/Zip:

HomePhone() Candidate CellPhone( )

Birthdate:Highschoolgraduationyear:School Email(Pleaseprintclearly): T-shirtsize:S M L XL Parents’/Guardians’Names:

Address(ifdifferent):City/State/Zip: Phone( )

Church:Pastor’sName: Address: City/State/Zip: Phone( )

Listschool,communityand/orreligiousorganizationsinwhichyouarecurrentlyactive:

StatebrieflywhyyouwishtoparticipateinaChrysalisFlightandwhatyouexpect:

Yoursignature: (Note-CampWanakeisanon-smokingfacility)

TO BECOMPLETEDBYPARENTOR GUARDIAN

Doesyourteenhaveanyhealthconditions,physicalhandicaps,allergies,medicationor

dietaryrestrictionsthatneedtobebroughttotheattentionofthe staff?(IfYES,please explain.)

haspermissiontoattendtheChrysalisWeekend. Intheevent ofanemergency,the Chrysalisstaffhaspermissiontosecuretheservicesoflicensedmedical professionalstoprovidethecarenecessary,includinganesthesia,formychild’swellbeing.

Parent/GuardianSignatureDatePhone( )

IfI/Wecannotbereached,call

Phone() Relationship

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NortheastOhioChrysalis

Flight(15-18YearsOld,HighSchoolSophomore-Senior)Information

Sponsor

Candidate’sName______Date of Flight: Boys June 3-5 @ Camp Wanake

Sponsor’sName______Girls June 10-12 @ Camp Wanake

Address Phone()City/State/Zip Email Weekendyouattended Date

Areyouinareuniongroup? YES/NO Doyouattendgatherings? YES/NO

Howlonghaveyouknownthecandidate? WhydoyouthinkyourcandidatewillbenefitfromaChrysalisFlightWeekend?

DoestheCandidatehaveareasofsensitivitythatcanbesharedwiththeLayDirector?

Haveyou explained: ChrysalisSiteYES/NOTransportationYES/NOtothecandidate?

thatparentscanattendclosing?YES/NO

Have you invitedparentsto: send-offYES/NO andClosing?YES/NO

Pleaseindicatewhowillbepayingthe$150expenseoftheweekend:$Candidate

$Sponsor/$Church/$Other(Partialscholarshipavailable. Contactregistrar.)

Sponsor’ssignaturerepresentsan understandingofthesponsor’sresponsibilitiesand commitmenttosupportthecandidate. (NEOCrecommendsyouthhaveanadultco-sponsor)

Sponsor’ssignature Co-Sponsor’ssignature

Pastor,yoursignaturerepresentsthat,tothebestofyourknowledge,thecandidatehas thephysicalandmentalhealthneededfortheChrysalisFlightweekendandisan active memberinthecongregation.

Pastor’sName(print)Phone()Signature Date

PleasesendCandidateSponsorformswith$50 depositfee(madepayabletoNEOC)to:

NortheastOhioChrysalis c/oDenny Hoxie

1297 Summit Dr.

Mayfield Heights,OH44124

DirectquestionstoDenny Hoxie,Registrar,at(440)520-4095or

Registrarmust receivethese formsnolaterthan2weekspriortotheFlightdate.

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