Name of Applicant _________________________________________________ Phone ___________

Address ______________________City ______________________State _______Zip Code ________

e-mail _____________________________________________________________ Age _______

Date of Flight I would like to serve on _________________________

• Youth will be asked to assist adults in charge of the Big House through the weekend. You will not leave the camp unless Big House adult requests you do so.
• Any Chrysalis youth may apply for the Big House.
• Applications will be processed on a first come, first served basis. Must have written or verbal notification within 48 hours of flight.
• Please come prepared to SERVE! Bring semi-formal clothes to wear to serve the special dinner on Day 2 of the flight. No strapless, spaghetti strap or halter dresses and not too short.
• If you are staying in Big House you are not to drive to candlelight unless you are 18 years of age or older. Theree will be adults available to drive you there and back to camp. This is for your safety.
• Please realize this is a Christian environment and you are here to serve. We ask for you to refrain from any behavior that would not be acceptable in Christ’s eyes. You may be asked to leave if such behavior is not acceptable.

My son/daughter ______________________ has my permission to participate in the support team activities of Piedmont Chrysalis for the above named dates. During this time I may be reached at this # ___________________________

_____________________________________

Parent’s signature/date

**Please attach copy of youth’s health insurance card**

I promise to participate fully and support team activities of the "Big House". I understand my service begins at sponsor’s hour on Day 1 and ends following Closing on Day 3. I am willing to commit my service work and prayer for this weekend to the advancement of God’s kingdom.

_________________________________
Applicant’s Signature / Date

Andrew Coward
4705 Shadow Lane
Climax NC 27233

Make checks payable to Piedmont Chrysalis – Big House
Questions please call: 336-674-0676

: