Application to Attend a flight

Guidelines

Use this form to provide an online application to attend a Flight.

You can then print it and send it with the deposit or Payment.

The total cost for the walk is $180 per person (One Hundred and Eighty Dollars)

A $60.00 (Sixty Dollars) is deposit required with this application.

Fees and Deposit can be paid by Direct Deposit/Internet Banking.

Bank Account BSB: 082 286

Acct No: 83670 3689

Acct Name: Sydney Regional Chrysalis

include Fees, First Initial and Surname
Applicant Details
Name * First Last
Preferred Name for Badge *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone Number
Mobile Number
Email
Date of Birth * / DD / MM YYYY
Male/Female * Male Female
Flight Applying For *

Please select the flight you are applying for
Do you have an Medication or Special Diet or health problem * Yes No
Are you on medication or a special diet or do you have any health problem that may affect your attendance at a Chrysalis weekend
Medical Dietary Information
None
If you said yes to the question above how can we help?
Dietary & Medical Information * Skin Conditions Disability or Chronic Illness Epilespsy, fits or blackouts Diabetes Asthma Allergies Allergic to any medication Other Epipen Vegetarian Vegan Lactose Intolerant Coeliac (Gluten Free) Food Allergies Peanut Allergy Other Nut Allergy Nil
Please tick all that applies. Please provide details
Why would you like to attend a chrysalis flight
Signature
Parent/Guardian Information

required for under 18's I have read "What is a Chrysalis weekend" and give permission for the applicant to attend
Name First Last
Phone No
Mobile
Email
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Signature
Minister/Pastor of Applicant's Church I know the applicant and encourage him/her to attend a Chrysalis weekend
Title
Name First Last
Name of Church
Address of Church
Minister/Pastor Signature and Date
Sponsor Details (a member of the Chrysalis or Emmaus Community)
Name * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone

phone number with no spaces
Mobile

Mobile No with no spaces
Email
Name of Next Steps or Reunion Group
Chrysalis or Emmaus Community Name
I will help the applicant into a chrysalis "Next Steps group Yes No
Why do you commend this applicant
Complete the form and submit. Please print a copy from your email when received, obtain the signatures and send to the registrar Jo Prunty with payment Send to Jo Prunty 20 Dabage Place Kurrajong Heights 2758
Upload Scanned copy of Application form

Application to Attend a flight

Application to Attend a flight

Guidelines

Applicant Details

Parent/Guardian Information

Minister/Pastor of Applicant's Church I know the applicant and encourage him/her to attend a Chrysalis weekend

Sponsor Details (a member of the Chrysalis or Emmaus Community)

Complete the form and submit. Please print a copy from your email when received, obtain the signatures and send to the registrar Jo Prunty with payment Send to Jo Prunty 20 Dabage Place Kurrajong Heights 2758