Chrysalis Application Page 1 of 2

NAME _____________________________________________________________________

ADDRESS __________________________________________________________________

CITY ____________________________ STATE ____ ZIP _________ - _____ (9 Digits)

Name desired for Name Tag: _____________________________________________________

Home Phone: __________________ Church you attend ________________________________

Birthdate _____________ Age______ Sex School ________________________ Grade F S J S

Applicant must be at least 15 years of age or have entered 10th grade. Applicants over 19years of age will be considered, yet may be encouraged to attend Walk to Emmaus.

Religious/Community/School activities you are active in ________________________________

Has Chrysalis been explained to you? _______ Has reunion been explained to you? _____

State briefly why you wish to participate in Chrysalis and what you expect:

REQUIRED SIGNATURES:

Applicant Signature _________________________________________ Date________________

Sponsor(s) Signature ________________________________________ Date________________

Sponsor Address: _______________________________________________________________

Youth Minister/Pastor Signature_______________________________ Date________________

Y. Minister/Pastor Addr: _________________________________________________________

 Chrysalis has its roots deeply planted in its parent movement, 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 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.

A $15 deposit is requested to off set the cost of the weekend. Make checks payable to San Diego Chrysalis. For those under 18 years of age, complete Authorization on back.