Register for Spring 2025

The Chrysalis Program

2024-2025 Online Application

REGISTRATION FOR Spring 2025 IS OPEN.

The Chrysalis Program is offering Saturday Sessions, Mentorship, Enrichment Trips and more to its members. Register today.

* Indicates required field

Student Name *

First

Last

Guardian Name *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Does your family receive any of the following: *

Illinois Medicaid SNAP Food Benefits Section 8 Housing None

I commit to: *

In Person Workshops once a month Virtual Check-ins Bi weekly Quarterly Community Events Monthly Family Outings

Program Participation Type *

School Name and Grade *

Date of Birth *

Food Restrictions/Allergies *

As a parent/guardian, I will likely *

What do you hope student will gain from enrolling in the Chrysalis Program? *

Submit

**By submitting this form, I hereby waive The Chrysalis Program, its officers, board and employees from any liability that may arise due to personal injury, loss or damage to personal property that may arise from volunteering for the Chrysalis Program or participating in a volunteer event. As a volunteer I understand that I am not covered under the insurance policies of the Chrysalis Program. I acknowledge that I understand the waiver described in this document. This waiver is made to the maximum extent permissible under applicable law.