Chrysalis Caterpillar (Guest) Registration Form

Upcoming Weekend Dates:

Boys and Girls: January 14th (Saturday)-16th (Monday), 2023 -Wabash Presbyterian Church, Orio, IL- Lay Director Chuck Kurfman

Guest Name (First and Last)(required)

Preferred Name on Name Tag and T-Shirt Size(required)

Age at the time of the weekend in January 2023(required)

Your Mailing Address(required)

Email Address(required)

Parent Name and Phone Number (required)

Caterpillar (Guest) Phone Number(required)

Sponsor's Name(required)

Home Church and Pastor/Youth Pastor's Name(required)

Are you allergic to any foods or other Materials ? If yes, do you have an Epipen?(required)

Do you have any health issues that we should be aware of?(required)

Emergency Contact Name and Phone Number(required)

What are some of your hobbies and interests?(required)

What are you hoping to get out of your Chrysalis weekend?

Your sponsor (the person who invited you) will be responsible for paying your $75 fee for the weekend and providing transportation to and from the weekend. He or she should also explain reunion groups and community gatherings with you. Once you have been accepted as a participant, an email will be sent to you and your sponsor detailing your packing list and other important information about the weekend. We look forward to seeing you in January! Please acknowledge that you have read this information by typing "yes" below.(required)

Trouble Shooting:

If you have trouble submitting this form, please contact Community Lay Director, Kaitlyn Lasswell, at wvem22@gmail.com, or Chrysalis Lay Director, Rachel Frederick at rachelfred123@gmail.com.