CAMPBELLSVILLE CHRYSALIS

CANDIDATE APPLICATION

Please Fill All Blanks Of Application (With 'N/A" If Necessary)

(Please provide all information requested or it could delay your acceptance.)

Candidate's Name*

Full Name (As You WIsh It To Appear On Your Name Tag)*

Phone*

Email*

Gender*

Male

Female

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

T-Shirt Size

2XL

3XL

4XL

5XL

Email (MUST HAVE- THIS IS HOW YOU WILL BE INVITED):*

Parent's Name:*

School:*

Grade:*

Do You Have Medically Necessary Dietary Needs That The Kitchen Needs To Plan For? *

Yes

***We Do Not Provide Diet Menus Such As Low Fat, Low Carb etc.***

Unless It Is Medically Necessary.

If Yes, Why?*

Do You Have Heath Problems, Allergies Or Physical Handicaps That May Affect Your Attendance At The At The Walk To Emmaus?

Yes

If Yes To Question Above, What?*

Are You On Special Medication That The Walk Leaders Need To Monitor For You?

Yes

If Yes To the Question Above, What? And When?*

Name & Denomination Of Church Attending*

Pastor's Name*

In What Religious or Community Organizations Are You Active?*

What Extracurricular Activities Are You Involved In?

I Intend To Be Present For The Entire Walk To Emmaus (THU 6:30pm - SUN 4:40pm)*

Yes

Candidate's Signature

Signature field is empty.

CONTACT US:

info@campbellsvilleemmaus.org

Campbellsville Emmaus Community

PO Box 4155

Campbellsville, Kentucky 42719

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