Chrysalis Flight Application
Board Approved January 2022 CHRYSALIS LEXINGTON EMMAUS COMMUNITY REQUEST FOR RESERVATION PLEASE INDICATE CHOICE Boy’s Flight (date) ______________________________ Girl’s Flight (date) ________________________________ The Chrysalis is a three-day experience of renewal, learning and sharing in an atmosphere of Christian community. It is designed for those from Freshman through Senior in high school. A chrysalis is a cocoon state of a butterfly. The symbol: caterpillar -- CHRYSALIS -- butterfly is thus used to represent the death, resurrection and new life found in Christ. It is the intention of CHRYSALIS to encourage each young person to experience this new life in Christ, "emerging" into a more beautiful and true self through worship, scripture, systematic teaching and living in the Christian community, to the end that we all might live out our faith in God through Christ by the power of the Holy Spirit. To insure your reservation we require a $25.00 non-refundable registration deposit. Return this completed form and your deposit to your Sponsor TO BE FILLED OUT BY THE CANDIDATE NAME_____________________________________________________ PREFERRED NAME (for name tag) __________________ ADDRESS _____________________________________ CITY __________________________ STATE __________ ZIP ________ PHONE # (______)_____________________ SEX: MALE ______ FEMALE ______ EMAIL ADDRESS: _______________________________________________________________________________________ DATE OF BIRTH: _______________ AGE (AT TIME OF FLIGHT) ________ GRADE in SCHOOL ________________________ SCHOOL ____________________________________ EMPLOYER (if working) ___________________________________________ CHURCH AND DENOMINATION ________________________PASTOR'S NAME & ADDRESS_____________________________________________________________________ CHURCH PHONE (______)______________________ What other Christian or community organization are you active in? _____________________________________________________________________________Has Chrysalis been explained to you? ______ Has the follow-up program (group reunions/gatherings) been explained to you? _____ Are you on a special diet? ______ Are you on medication? _______ The weekend will involve sitting in a conference room for a good part of the day, and some walking -- do you have any health problems or physical handicaps which may affect your participation in the Chrysalis Weekend? ________ (Please use the comment section below to explain any “YES” answers to the last three questions.) State briefly why you wish to be involved in the Chrysalis Weekend and what you expect to receive from it. ________________________ __________________________________________________________________________________________________________________________________________________________ In addition to your pastor who is listed above, please add the name(s) of a youth counselor or teacher who knows you well. Name ___________________________ Position ______________________________________ Phone ____________________ Name ___________________________ Position ______________________________________ Phone ____________________ Your Signature ____________________________________ Date ___________________ Parent Signature _____________________________________ Date ____________________ All of the above information is necessary for your proper placement in Chrysalis. Please fill in all the blanks. The cost of the weekend is $75.00 per person. We require a $25.00 registration fee (nonrefundable) which should be given to your sponsor along with your completed application. The remaining amount will be collected at the Registrar’s table upon your arrival. Please make checks payable to LEXINGTON EMMAUS COMMUNITY. A limited number of partial scholarships are available if requested early in the application process. This form is an application and its submittal does not guarantee acceptance. You may be placed on a waiting list since there are a limited number of spaces available on each weekend. Early applicants will be notified of acceptance by letter several weeks prior to the Chrysalis. Late applications will be processed as quickly as possible. Sponsor’s Name ______________________________________________ Address Phone (____)________________________ EMAIL ADDRESS: _________________________ADDITIONAL COMMENTS: Board Approved January 2022 CHRYSALIS LEXINGTON EMMAUS COMMUNITY REQUEST FOR RESERVATION TO BE FILLED OUT BY THE SPONSOR (Please fill in all sections and blanks!) Candidate’s Name _____________________________________________________________________ Your Name ________________________________ Address ___________________________________ City ______________________State ____________ Zip ____________ Telephone: Home (_____)_______________________ Work (_____)_______________________ Email Address: _______________________________ Name and Denomination of church now attending ____________________________________________ Do you attend regularly? ______________ Where was your Walk to Emmaus/Cursillo?______________ When? __________________ Emmaus/Cursillo # _______________ Reunion Group (y/n) ___________ Group? ___________________ Meeting Date/Time? ________________ Location? ________________ How Are you praying for the candidate? __________ Have you signed up for the Prayer Vigil? ________ Will you clear your weekend and attend the community events? _________________________________ Are you serving and sacrificing for your candidate’s weekend? __________________________________ Agape? ______________ Kitchen? ______________ Team? ______________ Other? ______________ Why do you feel this person is a good candidate? ____________________________________________ __________________________________________________________________________________________________________________________________________________________________ Does the candidate have the physical and mental health needed for a Chrysalis weekend? ___________ Is the candidate under any temporary emotional or physical strain that might indicate her/his weekend should be postponed? _______________________________________Are you able and willing to assist the candidate get into a reunion group? _________________________ Have you explained the gathering? _________ Will you accompany the candidate?__________________ Are you aware of the importance of minimal contact with your candidate during the weekend, especially if the candidate is your son or daughter? _____________________________________________________ It is the responsibility of the sponsor to ask the candidate's pastor/youth counselor/teacher to complete and return the reference information form. The Emmaus/Chrysalis leaders will keep this information in strict confidence, but it is important that it be received to complete the application process. When you deliver this form, include a stamped envelope address as shown below. Encourage the reference person to complete it and mail it within three days. Check back after three days to make sure the form has been mailed. Make sure you fill out the "name" and "date" section of the form. Thank you. Sponsor’s Signature __________________________ Date _________________ Mail to: Lexington Emmaus Community Attn: Registrar P.O. Box 23554 Lexington, KY 40523-3554 FOR OFFICE USE: DATE REC’D AMT REC’D CHECK NO. NAME ON CHECK Board Approved January 2022 CHRYSALIS LEXINGTON EMMAUS COMMUNITY REQUEST FOR RESERVATION REFERENCE FORM (Name) _________________________________ has applied to attend a Chrysalis Weekend to be held in the Lexington Area (Dates) _____________________. The Chrysalis is a youth version of the Walk to Emmaus. Chrysalis is a three-day spiritual renewal retreat that provides participants an opportunity to learn more about faith, to experience Christian love and support, and a chance to make new commitments in their faith journey. The content of the three days focuses on God's grace, how one experiences Christ as friend in the body of Christ, and how one is called into discipleship, giving love to a needful world. Chrysalis is for young men and women who are from sophomore in high school and at least 15 years old through sophomore in college but no more than 20 years old. You have been requested by the youth named above to serve as a "reference" for the application process. Your honest answers and observations related to the categories listed below will greatly assist the leaders of the weekend to make it the very best possible experience for each candidate. Your answers will be held in strict confidence. Thank you for your interest in the candidate's spiritual development and for taking time to complete this form. Please mail it in the envelope provided within three days. PLEASE CIRCLE THE APPROPRIATE ADJECTIVE AND COMMENT AS NECESSARY MATURITY: Immature Average Mature Very Mature COMMENTS _____________________________________________
EXERCISE OF LEADERSHIP: None Poor Good Excellent COMMENTS _____________________________________________________________________________ AREA OF LEADERSHIP: Church School Athletic Social Student Gov't Drama Musical Other COMMENTS _____________________________________________________________________________ PHYSILOGICAL ADJUSTMENT: Poor Average Good Excellent COMMENTS _____________________________________________________________________________RELATIONSHIP TO PEERS: Quiet Reticent Talkative Domineering Well-Liked COMMENTS _____________________________________________________________________________On a separate sheet please furnish any additional comments that you feel could help the team to understand and deal sympathetically with the candidate. Comments about the student's home life, personality, attitude toward life, maturity of faith, or any other significant information, might be of great help in placing the candidate where he or she might best benefit from the weekend. Name of person filling out this form: ________________________________________________________________________ How long have you known the candidate? _______________ In what capacity have you known the candidate?_____________________________________________________________________________________________________ Once again, please return this form in the envelope within three days. The Emmaus leaders will keep this information in STRICT CONFIDENCE. Mail this completed form to: Lexington Emmaus Community Attn: Registrar P.O. Box 23554 Lexington, KY 40523-3554 THANK YOU!