CYIA Registration 2023

Christian Youth In Action® 2023 Registration
Thank you for your consideration to serve the Lord with Child Evangelism Fellowship^®. You will need to complete this form in its entirety for your registration to be processed. You will need to e-sign your name as agreeing with these items and a parent or guardian must also e-sign with and for a minor (under 18).

If you have questions or need assistance, please contact us at (818) 349-9883 or stateoffice@cefsoca.com.

Registration Deadline is June 1, 2023.
Personal Information- Part A
Name*

First NameLast Name
CEF Chapter Name*
I am a*

New StudentReturning Student
If returning student, how many times have you attended CYIA?
Gender*

MaleFemale
Cell Phone Number*

Area CodePhone Number
Home phone*

Area CodePhone Number
Best Phone to contact you*

CellHome Phone
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*

Confirmation Email
Parent/Guardian's E-mail if under 18

Confirmation Emailexample@example.com
Name of Parent/ Guardians if under 18
Age Now*
Birth Date*

MonthDayYear
Year in School as of January 2023*
T-Shirt Size (in adult men's sizes*
How did you find out about CYIA?

Christian Life- Part B

God's been working in your life, and we'd like to hear about it!
Your Relationship With God
Why should (shouldn't) God allow you into heaven?*
Please share how you are growing in your relationship with Jesus Christ. How is God working in your life right now?*
How often do you read your Bible and pray (devotions)?*
Your Relationship With Church
How Often do you attend church?*
In what ways are you active in your church? (such as youth group, ushering, choir, outreach groups, mission trips, Sunday School)*
Church Name*
What city is your church located in?
Pastor or Church leader's name*

Summer Ministry- Part C

We would like to know some more about you so we can help you serve as an effective summer missionary!
Required for NEW student only: Why do you want to serve as a summer missionary (CYIA'er)?
Required for RETURNING student only: Why do you want to serve again as a summer missionary (CYIA'er)?
Please list any special training, abilities, and/or interests you have. (For example, guitar, sports, web design, writing, puppetry, storytelling, etc.)*
List any experience(s) working with children or youth (such as Sunday School teaching, Awana's, coaching, camp counselor etc.)*
Have you ever been convicted of or charged with physical or sexual abuse of a minor?*
Have you ever been dismissed or asked to resign from a position due to moral impropriety?*
Have you ever had a conviction other than a minor traffic violation?*
Do you have a driver's license?*
Would you or a family member be willing to help with driving to clubs? (Must be 25 years or older)

Medical Information- Part D
List any serious illnesses you have had.*
List any prescription medication you are currently taking.*
List any allergies you have (including food, medication, animals, etc.).*
If you have any medical or physical conditions that may require accommodation during training week or our summer ministries (including 5-Day Clubs, and fair ministries), please explain using the text below or contact CEF State office at 818-349-9883 or stateoffice@cefsoca.com.
Additional medical explanation box.
Emergency Contact Information

Primary Contact
Name of Primary Emergency Contact*
Relation to student*
Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Secondary Emergency Contact Information
Name of Secondary Emergency Contact*
Relation to student*
Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Medical Care Release

If a minor is applying, I am the parent/guardian of the above-named student.

I hereby give full permission for emergency medical treatment for my child while he/she is in the care of Child Evangelism Fellowship of Southern California, Inc. I understand that necessary precautions will be taken to ensure my child's safety while participating in the Christian Youth in Action^® program, including 5-Day Club^® and related activities.

If you are a minor (17 and under), your parent needs to sign below to indicate that you are in agreement with the above statement. If you are 18 and older, please sign below to indicate that you are in agreement with the above statement.
Signature-use your mouse to enter your signature
Enter Date

MonthDayYear
Medical Insurance Information*

CarrierPolicy No.Subscriber's NameHealth Group No.
No Insurance

Check here ONLY if you do NOT have coverage under medical insurance.

Waiver/ Release- Part E
Travel Waiver for Minors

Item number six of the Child Evangelism Fellowship (CEF^®) USA Child Protection Policy fact sheet states, "Even when ministry to children is not taking place, an additional adult or minor must be present when two workers are together and one is a minor, unless the minor’s parent or guardian has signed a waiver."

I understand that there may be occasions when my child may be traveling from location to location in the company of only one adult of legal age.Therefore, I, the parent or legal guardian of above-named student, a minor, hereby waive the above requirement for this minor and give my permission for him/her to travel and serve with Child Evangelism Fellowship without being accompanied by two or more adults at any given time.
Travel Waiver (choose one)*
Liability Release

"In the unlikely event that my child (or myself if 18 or older) is injured while participating in activities at Christian Youth In Action®, 5-Day Club® and other official CEF™ activities or in route to such activities, my child and I relinquish all rights to recover damages for any and all injuries sustained by my child (or myself). In consideration for CEF granting my child (or myself) permission to participate at CEF activities, I hereby release Child Evangelism Fellowship of Southern California, its employees and volunteers from liability for injuries occurring in CEF activities."

"I further acknowledge that my child (or myself) is responsible to fasten his/her seatbelt and to abide by all traffic laws while involved in CEF activities or in route to such activities."
Liability Release (choose one)*
Photography and Video Release

Child Evangelism Fellowship® may, from time to time, document the activities of the ministry with photos or videos. I hereby assign and grant to Child Evangelism Fellowship Inc., its subsidiaries and successors, and assign the unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes.
Photography and Video Release (Choose one)*
Full Name of Applicant*

First NameLast Name
Parent or Guardian Signature or Applicant over 18*
CYIA Agreement:

As a CYIA’er for CEF of Southern California, I shall strive to:
1. Attend pre-training with my local chapter.
2. Model the Christian lifestyle, whether in class and elsewhere in my relationships with children, CEF representatives, or CYIA team members.
3. Maintain my own spiritual health through daily Bible reading and prayer.
4. Endeavor not to be a stumbling block to any child, parent, or fellow CYIA’er.
5. Follow the policies CEF has established in the Code of Conduct to the best of my ability.
6. Be willing to volunteer help above and beyond my specified duties.
7. Be cheerful in the execution of my duties.
8. Commit to praying for the children I will be reaching and fellow CYIA’ers.
9. Cheerfully submit to the authority of the CEF director and representatives.
I understand that CEF will in return:
1. Help me with problems I face as a CYIA’er.
2. Demonstrate leadership characteristics and be encouraging to CYIA’ers.
3. Help me adjust to my responsibilities and acquaint me with CEF goals, philosophies, and policies.
4. Will not discriminate on the basis of race, sex, national origin, age or handicap.
I agree with the above statements. I fully intend to follow all CEF policies and procedures to the best of my ability.

All the answers on this online registration are truthful to best of my knowledge.
Applicant's Signature*
Parent Signature (if applicant is a minor)

I give permission for my teenager to participate in the CYIA™ program. I reviewed all of the information of the application. I fully understand the requirements of the program.
Parent Signature
Date*

MonthDayYear
Should be Empty:

Christian Youth In Action® 2023 Registration

Personal Information- Part A

Christian Life- Part B

Your Relationship With God

Your Relationship With Church

Summer Ministry- Part C

Medical Information- Part D

Emergency Contact Information

Secondary Emergency Contact Information

Waiver/ Release- Part E