Application to work on a Chrysalis

By signing this release, you authorize Puget Sound Chrysalis:

1. To conduct this retreat with your participation during any conflicting events, including school (please be aware that this weekend experience lasts from Thursday night to Sunday afternoon and your participation is required during the entire event).
2. In compliance with clergy guidelines, information provided by youth during the retreat weekend will be respected as confidential. However, state law requires Puget Sound Chrysalis and its leaders and clergy to report information about abuse to or by youth to appropriate authorities.
3. NOTE: State Patrol background check will be conducted for all persons 18 and older, in accordance with state law.

You may also download a printable PDF version of this application. (Note: if you do not already have Acrobat, you will need to install the free Acrobat Reader to use PDFs.)

Personal Information:

Important: Full name must be shown exactly as it is on your driver's license.

First:                                                                                 

Middle:                                                                              

Last:                                                                                 

Preferred name/nickname (for your nametag):                                         

Mailing Address:                                                                                 

City:                                          Zip:                      

Home Telephone including Area Code: (         ) and Number:                                         

Email:                                                                                                                          
(Must include @ and period [.], and must end in a well-known domain or two letter country)

Age                 Date of Birth         /        /           (month/day/year—as shown on drivers license)

Gender   [   ] Male     [   ] Female

When did you make your Chrysalis weekend?          /        /           (month/day/year)        

What was your Flight's number? #        

Where was your Flight?                                                                                             

PARENTS/GUARDIANS: If your child is under 18 years of age, we must have your authorization in writing for the youth to participate as a team member. Please sign the section at the end of this form.

What DATES would you like to work?

NOTE: Flights are for youth 16 to 19; Journeys are for young adults 18 to 24
Write number showing ranked preference (1 for first choice, 2 for second, and so on).

[   ] Spring Boys Chrysalis (Feb./Mar.)		[   ] Spring Girls Chrysalis (Feb./Mar.)
		[   ] Summer Girls Chrysalis (July/Aug.)
[   ] Summer Young Mens Journey (July/Aug.)		[   ] Summer Young Womens Journey (July/Aug.)
[   ] Fall Boys Chrysalis (Oct.)		[   ] Fall Girls Chrysalis (Oct.)

What AREAS would you like to work?

Write number showing ranked preference (1 for first choice, 2 for second, and so on).

[   ] Speaker
[   ] Table Leader (not giving talk)
[   ] ALD
[   ] Kitchen
[   ] Agape
[   ] Love Team (We always need your help here)
[   ] Song Team (List your musical talent below)
    [   ] Soprano
    [   ] Alto
    [   ] Tenor
    [   ] Bass
    [   ] Guitar
    [   ] Piano
    [   ] Other Instrument(s) (Please be more specific about other instruments below)

                                                                                                    
[   ] Assign me anywhere
[   ] Not in the above list (Please explain below about the unlisted area of service you suggest:)

                                                                                                                                 

Have you ever worked a Chrysalis weekend before?

Please check only one.
[   ] Yes
[   ] No

Chrysalis Work Experience:

Write as much as you need. If no experience, write "No Experience" Use additional paper as needed

Special Talents:

Write as much as you need. Describe any special gifts you feel might be useful on the Flight. Use additional paper as needed

Medical Release:

I attest that I am in good health and had a physician's physical within the past two years.
[   ] Yes
[   ] No

Tell us about any medical issues which might affect you during the weekend. Use additional paper as needed. Please note this will not exclude you from working, but it will assist us in being prepared for potential emergencies. Depending on the nature of the medical issues, we may request a copy of the physician's report for our records.

Special Diets:

Please tell us about any special foods or diets that you require. Use additional paper as needed. This will help the chef prepare foods that are safe for you.

Are you planning to sponsor a Caterpillar on the Flight you'd like to work?

Please check only one.

[   ] Yes [   ] No

|                       |

Your participation in the Sponsor's Service is very important. Please make sure your team leader knows of your commitment before the start of the Sponsor's Service.

I agree to abide by the Team Member Covenants

Please print out the team covenants at http://www.gbgm-umc.org/ps_chrysalis/teamcovs.htm and be prepared to show it to your team leader or lay director. Then sign the following:

As a member of Puget Sound Chrysalis, I understand and agree to the team covenants and their values. I have read these covenants, prayerfully considered the implications, and understand that I am setting a Christian example for the Caterpillars, fellow team members, the Chrysalis community, and the world.

Did you review the team convenants and print them out for reference?
[   ] Yes
      Expect to be reminded at team meetings and in messages from your Lay Director.

Signature                                                                   Date                                 

Would you be willing to serve on the Puget Sound Chrysalis board of directors at some time in the future?
All youths and adults are eligible to serve.

Please check only one.
[   ] Yes
[   ] No

Signature                                                                   Date                                 

Parent's signature is required if worker is under 18

I understand the nature and purpose of the Chrysalis weekend and I have read the important note below. I am the parent/guardian of the youth named on this form and hereby give my authorization for his/her participation as a team member.

Parent/guardian signature                                                                   Date                                 

Print parent/guardian name                                                                               

I am the  parent  /  guardian  (circle one) of this youth.

IMPORTANT PARENT/GUARDIAN NOTE:
By signing this release, you authorize Puget Sound Chrysalis:

1. To conduct this retreat with youth's participation during any conflicting events, including school (please be aware that this weekend experience lasts from Thursday night to Sunday afternoon and youth's participation is required during the entire event).
2. In compliance with clergy guidelines, information provided by youth during the retreat weekend will be respected as confidential. However, state law requires Puget Sound Chrysalis and its leaders and clergy to report information about abuse to or by youth to appropriate authorities.

Mail this work request right away

When completed, please mail this form and your $50.00 work fee to:
Puget Sound Chrysalis, Registrars, P.O. Box 21528, Seattle WA 98111-3528

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