Parental consent

We ask that the person who completes this parental consent form is a parent or legal guardian of the applicant. Only one parent or legal guardian is required to fill out our parental consent form. The purpose of this form is to confirm that you do agree to give permission to send your child on one of our upcoming Chrysalis Flights. Please note that optional fields are marked with an asterisk. We appreciate you taking the time to fill out this form of consent and for choosing to allow your child to be part of a Chrysalis weekend.

Applicant information

Your child's information

First name:Last name:Gender:MaleFemaleSponsor's first name:Sponsor's last name:Sponsor's email:

Parental information

Your information

First name:Last name:Gender:MaleFemalePrimary phone number: ###-###-####

*Secondary phone number: ###-###-####

Email:

The early bird fee to attend a Chrysalis Flight is $

100

and it's due one week before your child's Flight. If paid afterward, the cost becomes $

115

at the door. Please let us know how you intend to settle any balance that is owed for your child's Chrysalis Flight:

The balance that I owe:has already been paidwill be put in the mail as soon as possiblewill be paid by my churchhas been approved by the Chrysalis board of directors as a need-based scholarship

will total $

115

and will be paid at send-off

Getting your payment in on-time is the last crucial step for attending Chrysalis. If need be, payments can be made in installments. Need-based scholarships are available upon request by submitting an email to the Chrysalis board of directors. All checks should be made out to "CCCC" or "Central Carolinas Chrysalis Community" and sent to our address at:
‍

Central Carolinas Chrysalis
Attention: Registrar

PO Box 680003

Charlotte, NC 28216

Please enter the month and year for the Chrysalis Flight that your child plans to attend: (month, year)

Permission to use your child's contact information:

The contact information we are referring to is limited to your child's cell phone number and email address. This information would have been provided to us on your child's "Flight Application".

The purpose of asking for your permission to use this contact information in the future is solely to enable us to encourage your child after their weekend is over, seek their participation on future Chrysalis events and to allow those participants (youth and adults) who were on your child's Flight to stay in contact with one another.

YesNo

Authorization

Your signature:Today's date:

As a parent or legal guardian (the person filling out this online document), by placing your full legal name in the box above and by dating this parental consent form, you are authorizing us to receive your child for the duration of the Chrysalis Flight that you have indicated above.

Thank you! Your parental consent form has been received!

We have just sent an email that notifies your child's sponsor that you have successfully submitted this form. A "caterpillar" cannot attend a Chrysalis Flight without parent consent; so we appreciate the time you have taken to fill this out for your child.
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If you have any questions or concerns that we can address for you about Chrysalis, please feel free to contact any of our board members directly or you can send an email to:

centralcarolinaschrysalis@gmail.com

and we will be happy to respond. We look forward to getting to know your child on their Chrysalis Flight!
‍

- The Central Carolinas Chrysalis Board

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