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Cornerstone Chrysalis

OF SOUTHERN CALIFORNIA

CORNERSTONE CHRYSALIS of Southern California
Youth Ministry Yearly Activity Release

This release is meant to cover all Cornerstone Chrysalis youth activities held from Feb. 2024 - Feb. 2025, including but not limited to: retreats, sleepovers, small group activities, out-of-town activities, and local activities.

If at anytime you wish to withdraw your consent for any activity, written notice must be received before the activity.

The security and confidentiality of the information provided on this form is of the utmost importance to the Cornerstone Chrysalis Community and will be held and maintained in a secure manor.

MINOR'S INFORMATION

Minor's First Name

Minor's Last Name

Minor's Birthday

Minor's Email

Minor's Street Address

Minor's Phone

Prefer Texting

Yes

No

Mailing Address if different

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