App July 10th, 2017 Chrysalis Request For Invitation (Under 18) SPONSOR INFORMATION (please print legibly)Name Address Home PhoneCity, State ZIP Cell PhoneEmail Church Name/Denomination Church Address, City, State, ZIP When and where did you attend the Walk to Emmaus/Chrysalis? Candidate’s Name How long have you known the candidate? Please furnish any additional comments that you feel could help the team understand and relate with the candidate. Comments about the candidate's family, personality, attitude towards life, doubts, difficulties, and hopes may be of significance.Have you reviewed The Steps of Sponsorship? Yes No If you are sponsoring within 6 months of your weekend or more than one person on a si ngle weekend, you MUST have a co-sponsor. ALSO, if you are under 18 years of age you MUST have an Emmaus adult co-sponsor. Others may also have cosponsors to assist them. (Suggestion: Adult sponsors please)Sponsor Signature Date MM slash DD slash YYYY CO-SPONSOR INFORMATIONName Address Home PhoneCity, State, ZIP Cell PhoneEmail Church Name/Denomination Church Address, City, State, ZIP When and where did you attend the Walk to Emmaus/Chrysalis? How long have you known the candidate? Co- Sponsor Signature Date MM slash DD slash YYYY CANDIDATE INFORMATIONName Nickname Address Home PhoneCity, State, ZIP Cell PhoneEmail Do you check this regularly? Yes No Gender Male Female Date of Birth MM slash DD slash YYYY Church Name Pastor Church Address, City, State, ZIP In what church or community activities are you currently active? Please list three words that best describe you (quiet, easy-going, happy, reserved, laid-back, humble, modest, pleasant, good-humored, enthusiastic, indifferent, helpful, good-natured, smart, etc.): Are you on a special medication? Yes No Are you on a special diet? Yes No Are you on a special diet? Yes No Do you have physical limitations? Yes No Are you on a special diet? Yes No Are you on a special diet? Yes No Please explain any "yes" answers below:Please note that no written confirmation should be expected as a result of this Request for Reservation. Once selected for a weekend you will receive an invitation letter providing additional information on the weekend and instruction for acceptance. Any questions regarding the status of this Request for Reservation should be addressed to the sponsor(s).Candidate Signature Date MM slash DD slash YYYY Parent/Guardian Signature(s): Date MM slash DD slash YYYY Release of Liability and ConsentDISCLOSURE The purpose of gathering the information on this form is to provide leader(s) with the information needed to facilitate the activities of youth participating in the Chrysalis Weekend activities and to be able to respond in the event of an emergency. This form is to be completed and signed by the parent/guardian prior to the weekend.Name of participant Birth Date MM slash DD slash YYYY Address Home PhoneCity, State, ZIP Cell PhonePHOTOGRAPHY/VIDEO RELEASE Birth Date Home Phone Cell Phone Throughout the Chrysalis Weekend, leaders may take photos and/or video of persons participating in activities. These photos and/or short videos may be displayed on the Delmarva Chrysalis website and/or our authorized Facebook Group. Potentially some photos may be used in a Community newsletter, publication or promotional material in which case specific permission to publish names would be sought; otherwise, names are not published. By signing below, I consent to the use of images of child/ward as indicated. AUTHORIZATION FOR MEDICAL TREATMENT This release and consent gives Chrysalis permission to take my child to the nearest available medical facility and have any necessary emergency treatment administered. I understand that every effort will be made to contact me. However, in case of emergency, if I cannot be reached, I hereby give Chrysalis permission to act on my behalf in seeking medical treatment by qualified personnel for my child in the event that such treatment is deemed necessary or advisable for my child’s health, safety and welfare. I release Chrysalis and all medical providers from liability in acting on my behalf in this regard in rendering such medical treatment. RELEASE OF LIABILITY I understand that participating in Chrysalis activities is a privilege. In consideration of this privilege, I release Chrysalis, including its directors, volunteers, employees and agents from and against any liability or claims for any loss, costs, damages, or injuries (including reasonable attorneys' fees and expenses) in any way arising from their participation in the Chrysalis Weekend. I understand the program will include traveling by bus or in vans from New Castle County, Delaware to Camp Pecometh, Queen Anne’s County, Maryland, from Camp Pecometh to a nearby church, and from Camp Pecometh back to New Castle County, Delaware. If I am under 18, my parent or guardian, by signing below, also consents to my release and he or she agrees that this release shall be binding upon him or her as my parent or guardian as to me and my estate, heirs, personal representatives and assigns. My parent or guardian also promises, by signing below to defend, indemnify and hold Chrysalis harmless from any claim asserted by me against Chrysalis, including its directors, volunteers, employees and agents, if I should repudiate this release after obtaining adulthood. Signature of minor participating Date MM slash DD slash YYYY Signature of Parent /Guardian Date MM slash DD slash YYYY INFORMATION FOR EMERGENCIES Policy for participation in the Delmarva Chrysalis program requires that every participant have Health/Accident insurance coverage or waiver. In addition, certain Health/Medical information must be made known to the leader(s) conducting the program, so that they are prepared to respond appropriately if the need arises. This information will be held in confidence. Please complete the form and return it with your application. Δ
