referring someone to chrysalis

Serving as a reference

We ask that the person who completes the reference form is a pastor, youth pastor, counselor or a teacher who knows the candidate sufficiently. The purpose of the reference form is to assist us with their placement in a group where he/she will benefit the most. The information that you provide about the applicant is meant to be private and will remain confidential to us. Please note that optional fields are marked with an asterisk. Thank you for taking the time to serve as a reference for this young person and for providing this information so that we can set up for their best Chrysalis experience.

Reference form

Applicant information

Your caterpillar's information

Reference information

Your information

When giving us your rating in the areas below, please relate these answers to a regular church or youth activity. When making comments, please respond with how this person relates to people who are sophomores, juniors and seniors in high school. Comments are optional.


As a reference (the person filling out this online document), you are either a pastor, a youth counselor/pastor, a teacher or someone who knows the candadite sufficiently in order to make the assessment above. By placing your full legal name in the box above and by dating this online form, you are authorizing us to use this information solely for the purpose of evaluating the applicant's candidacy and how to best place the applicant in a small group of peers on their Chrysalis weekend.

Thank you! Your reference form has been received!

We have just sent an email that notifies the applicant's sponsor that you have successfully submitted this form. A "caterpillar" cannot attend a Chrysalis Flight without at least one reference so we appreciate the time you have taken to submit a reference form for this applicant.

- The Central Carolinas Chrysalis Board

Oops! Something went wrong while submitting the form. Please make sure all required fields are completely filled out and then try to resubmit. Please note that optional fields are marked with an asterisk.