Vision: A recognised global leader in holistic youth development

Mission: To provide a platform for youth to deepen their resilience and unleash their potential through
mental, physical, emotional and spiritual development, enabling them to be role models and agents of
positive change
What are we offering? In the Third Phase, students are exposed to different
technical and vocational skills during the four week
The Academy offers a 3-month intensive residential life Skills Phase. Basic Office administration & Computer
skills and leadership development programme to skills, Peace Officer, Security, Sports Coaching,
provide young people with the necessary tools to Hairdressing & Grooming, Youth Development and
become self-confident, resilient role models and Child & Youth Care are some of the skills on offer.
leaders within their communities.

We facilitate two males and one female course per Fourth Phase
A leading provider in holistic youth
year. Our three-month residential training is divided
development into four Phases, which are compulsory for all students.

As a foundation for our programme, a daily

routine is established where discipline and
compassion are emphasised.

First Phase

To ensure the sustainablity of the programme and as

part of the on-going development of our youth, the
Academy offers a 5 Year Aftercare to monitor and
assess the progress and needs of graduates in order
to provide employment, learnership and volunteer
opportunities where required.

During the Second Phase students participate in an

adventure leadership programme on the Outdoor
Phase. Here students head to the great outdoors for
The Chrysalis Academy is a youth leadership “The Chrysalis Academy has influenced me to recognise
two weeks, to test their personal limits; discover their that I have the ability to push myself to my limits and grow
development organisation, empowering young people strengths and weaknesses; develop teamwork and into a strong empowered young woman, and that every day
to take responsibility for their personal growth. leadership skills. Activities include extensive is a day for change” – Shadey October 16 BRAVO
mountain hiking, canoeing, raft building and a 24-
hour Solo Process.
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Life Coaching and Family Integration WHO SHOULD APPLY? (Our criteria) Contact details:

The Academy offers one-to-one individual counselling Young motivated people who want to Chrysalis Academy, Porter Estate, Tokai Road,
to all students on request or by referral. In addition, contribute to society by positively changing Tokai, 7945
working with parents is an integral part of the their lifestyle and; Private Bag X2
programme and three Parent workshops are Western Cape
presented during the 3-months training. ✓ are aged 18 to 25-years-old
✓ Have passed Grade 9 (Std. 7) mainstream Tel: 021 712 1023
Health and wellness is a critical aspect of the 3- schooling Fax: 021 712 1075
months programme, therefore students also receive ✓ Not in employment, education or training Email: [email protected]
education in leading healthy lifestyles. Precision ✓ Have no criminal record and Website: www.chrysalisacademy.org.za
drilling and physical training form part of the daily ✓ Is a resident of the Western Cape Province
student programme. In addition, students are
afforded a range of therapeutic care programmes like
Mindfulness, Art and writing, Yoga, Trauma Release HOW TO APPLY?
Exercises (TRE), Meditation & Art, Support groups
and Tai Chi. Please fax or email to the Chrysalis Academy,
the application form on or before the closing
date together with a copy of your I.D; proof of Chrysalis Academy is funded by both the Dept. of Police Oversight
& Community Safety and Social Development of the Western Cape.
residence and your most recent school report
(see contact details on page 5).

All applicants who meets the application

criteria shall be notified of their interview date
by means of an SMS.

“Chrysalis had a positive impact on my son. He You will then undergo vetting, medical and a
acted so mature and confident when I saw him fitness assessment for the final selection.
for the first time. He looked healthy. I have Random drug testing may also be done.
started to be more patient, loving and
TAKE THE FIRST STEP, APPLY TODAY
considerate. I will not push him into the
direction I want him to go in to, but allow him to Successful candidates are required to pay a non-
set goals and achievements for himself.” - refundable fee only on the day of intake.
Parent
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Kindly note the documentation you must submit with your application, which is listed on the
Staple here last page. Please consider your application incomplete if you have not submitted the
aforementioned documents. Incomplete applications will not be processed.

PART A – STUDENT PERSONAL DETAILS *See POPI declaration on Page 5

Surname:

First names:

Id number:

Date of birth: D D M M Y Y Y Y Age

Gender Male Female Other Prefer not to answer

Prefer not to
Race Black Coloured White Indian Other
answer
Prefer not to
Marital Status Single Married Divorced Widowed
answer

Home Language Afrikaans English IsiNdebele Sepedi Sesotho Siswati

Xitsonga Setswana Tshivenda IsiXhosa IsiZulu Other

Disability Yes No Please specify if yes

PART B - CONTACT DETAILS

Cell phone

Email address

Street address

Area Area Code

Name of Local
Township/suburb Municipality

How long have you been staying at your current address?

In which area did you stay previously?

Is your postal address the same as your street address?

YES NO
Postal address: (if
not)
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PART C: DETAILS OF YOUR CURRENT/MOST RECENT STUDIES

What is your highest grade passed? Grd 9 Grd 10 Grd 11 Grd 12

Name of last school attended

What are you

In school Employed Unemployed Studying and not employed
doing this year?

Grd 10 Grd 11 Grd 12

If in school, what are you studying?
Part time courses Diploma Degree Other (explain below)
If other, explain:

Have you completed (passed) any Yes No If yes, what studying have you completed
studying after school? Part time courses Diploma Degree Other

Learner’s Licence Driver’s Licence None

Are you in possession of a valid If a Learner’s Licence, what is the expiry
date?
Driver’s Code A A1 B C1 C EB EC EC1

PART D: DETAILS OF YOUR FAMILY

Are both your parents alive? Mother Yes No Father Yes No

How many people including you are living in

Do you live in a female-headed household? Yes No
your home?

Name of Mother/ Stepmother/ Legal

guardian (Please circle)
What does your mother do? Employed Not employed Self-Employed Studying Other
Occupation, if employed
Business Disability Child support
Source of income Salary Pension None
Profit grant grant
Contact
Email address
Number

Name of Father/ Stepfather/ Legal

guardian (Please circle)
What does your father do? Employed Not employed Self-Employed Studying Other
Occupation, if employed
Business Disability Child support
Source of income Salary Pension None
Profit grant grant
Contact
Email address
Number

Do you have any family members who have been on course before? YES NO

If yes, name and surname of family member

How is the family member related to
In which year?
you?
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How did you hear about the Chrysalis Youth Chrysalis Community
Municipality Website Other
Chrysalis Academy? Hub Ambassador Graduate Worker
What means of social media platform do you use most?

• Are you prepared to make yourself available for a consultation and fitness assessment at the Chrysalis Academy should you be
contacted for an interview? Yes No
• I am aware that should it be found after being accepted onto the Chrysalis Academy programme that I submitted any false or
inaccurate information in connection with this application, I could be dismissed immediately. Yes No

In which capacity are you filling in this application form? Self ☐ Mother ☐ Father ☐ Guardian☐ Other ☐

POPI declaration (Protection of Personal Information Act)

Where required in terms of the Chrysalis Academy’s POPI Policy, the Academy must, and will, share your personal information
where it is in the best interest of the student. In particular, your data will be shared with provincial departments of the Western
Cape Government such as the Department of Police Oversight & Community Safety, the Department of Social Development, and
other prospective Government Departments. Your details may also be shared with external partners of the Academy in order to
provide additional services to students. Furthermore, your details will be submitted to RefCheck South Africa, for purposes of
criminal checks/vetting. By signing this application form you grant the Academy permission to share your personal information with
the Academy’s stakeholders as indicated.

Vetting/Criminal checks will be done on interview days at the Chrysalis Academy at a cost to the applicant

Signature of applicant
Date
Includes acceptance of POPI declaration

Please do not forget to attach:

• Certified copy of your ID,
• Certified copy of your last school report / Academic Qualification,
• your proof of residence, (i.e. Affidavit or your proof of bank account which contains your address)

Fax or email the completed application form to:

Academy, Porter Estate, Tokai Road,

Tokai, 7945
Private Bag X2
Western Cape 7966

Tel: 021 712 1023

Fax: 021 712 1075
Email: [email protected]
For online applications, please visit our Website: www.chrysalisacademy.org.za

Kindly note: No applicant should pay any community worker, government official, or anyone any fee to apply to the Chrysalis
Academy. The only money that is paid to the Chrysalis Academy is in the form of a non-refundable deposit when you are
accepted onto the course.