CHRYSALIS MEDICAL AUTHORIZATION
ALL information MUST be filled in, or application and fee will be returned.  

I am the parent/guardian of :_________________who has my permission to attend 
Chrysalis Flight#_______
What medications is the participant currently taking?(Please send medicine in the  orig-
inal prescription container, labeled with instruction and contents)________________
________________________________________________________________.
Any Allergies? If so, please list:_________________________________________
Are there any health concerns, special needs, diet restrictions or accommodations re-
garding the participant?______________________________________________.
Date of last tetanus: ____________________.
During this time I may be reached at:
Parent/guardian Name: ________________________ Phone # (    )____-_______
Address, City, Zip:__________________________________________________
Emergency Contact: ________________________Phone # (    )____-__________
Address, City, Zip: __________________________________________________

Family Physician: _________________________Phone# (    )___ -___________
Medical Insurance Provider: _______________Policy# ____________ Phone #(    )____-_____
[ ] I authorize Chrysalis Flight # ______ event staff/emergency physician/EMS personnel to pro-
vide medical treatment for my child if deemed necessary. 

Covenant of Behavior
(Revised SWTC 10/98)
        

  I (Name)___________________________________, agree that as a participant in a Southwest Texas 
Conference United Methodist youth event, I am expected to follow certain conduct standards which 
promote a healthy event experience for all. In keeping with these standards, I will not bring alcohol, 
tobacco, illegal drugs or firearms to the event, nor will I engage in inappropriate sexual behavior, nor will I 
intentionally cause the destruction or abuse of camp property.  I understand that failure to comply with the 
above will result in my expulsion form event, a phone call to my parents/guardians, pastor and/or youth 
director, and my suspension from  the next two Southwest Texas Conference youth events.
      I also agree not to bring any items which may interfere with the purpose of the event (such as fireworks,
 skateboards, stereos or tape players). I am aware that the event will be providing my meals and that I am not
 to bring any personal food items, have food sent or delivered or take food or drink into living areas. I agree to 
follow the daily schedule arranged for the event at all times, and at no time will I leave the event site. I under- 
stand that there will be no visitors allowed (including family and relatives) while this event is in progress and 
that there will be no visitation in rooms designated for the opposite sex. 
     If I should not act in accordance with this covenant while attending a SWTC event, I realize that I may be 
disciplined at the dean's discretion, up to expulsion from the event and suspension from  the next two SWTC 
events.  By my signature on the registration form for this event, I am indicating that I have read this covenant 
and accept my end of the agreement, with the expectation of an experience which leads to my own spiritual 
growth and enjoyment. 
Youth's signature _____________________________________________Date:____________________
My Son/daughter has accepted the responsibility of honoring the Covenant of Conduct 
Parent's signature ____________________________________________Date:_____________________

Revised 11/13/2002