CYIA Winter Blast Registration Form
Fill out the form carefully for registration
Student Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CEF Chapter
Please Select
Northwest Chapter (Dr. Ricardo Hosein)
Northeast Chapter (Mrs. Anna Durney)
Central Chapter (Mr. Jimmy Lundy)
Southeast Chapter (Mr. Anthony Frail)
Student E-mail
example@example.com
Mobile Number
Parent/Guardian Number
Emergency Contact
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General Medical History
Please complete this form so we can meet any special needs your child has & so we have enough information in case of an emergency.
Does your child have any food, medication or environmental allergies?
Yes
No
Allergies? Check all that apply.
Food
Medication
Environmental
Other
Please list and explain any allergies
Date of Last Tetanus or Diptheria, Tetanus, Pertussis(DTaP) Vaccine?
-
Month
-
Day
Year
Date Picker Icon
Does your child need any medications?
In addition to prescribed medications, my child has my permission to receive the following over- the-counter drugs:
Tylenol
Cough Syrup/Nasal Decongestant
Antihistamine
Stomach Antacid
Other
None
Additional Comments
MEDICAL CONSENT/LIABILITY RELEASE STATEMENT
I hereby release Child Evangelism Fellowship® Inc., its staff, board members, & agents from responsibility & liability for any injury or illness that my child may sustain during the above- mentioned CEF® program. I hereby give permission for my child to receive medical treatment in the event of an emergency. I expect to be contacted as soon as possible.I, the undersigned parent(s), or guardians(s), hereby consent to my teen participating in CEF summer ministries. I give my permission for my teen to be transported to and from this and any corresponding event by the CEF staff or volunteers.If my teen has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them below. In the event that an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached within a reasonable period of time, as determined by the CEF sponsors, I hereby authorize the sponsors to make emergency medical decisions for my teen. If there are any activities I do not want my teen to be involved in I have listed them below. I am aware of the religious nature of this event.I understand and agree to assume all of the risks which may be encountered during these events and irrevocably and unconditionally release and discharge Child Evangelism Fellowship and its agents, employees, and volunteers from any and all liability, actions, causes of actions, claims, expenses, obligations and damages of any nature whatsoever, which I now have or which may arise in the future, in connection with the described activity or associated activities, including, but not limited to, any injury to my child.I state that I have carefully read and understand the foregoing release and know the contents hereof and I sign this release as my own free act. I understand that this is a legally binding agreement.I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
By typing your name below, you are consenting to the Medical Consent/Liability Release Statement by the ministry of Child Evangelism Fellowship® of Wyoming. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Parent/Legal Guardian Signature
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Photo & Video Release
Child Evangelism Fellowship® may, from time to time, document the activities of the ministry with photos or videos of club activities. 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 advertising and promotional purposes.
By signing below, I am consenting to that photos and videos of my child can be used by the ministry of Child Evangelism Fellowship® of Wyoming.
Parent/Legal Guardian Signature
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My Products
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WinterBlast Registration Fee
Fee Covers all Meals, Transportation, & Lodging. Paying online includes a processing fee of ($3). If you do not wish to pay online a cheque can be mailed to CEF Wyoming PO Box 1866, Glenrock WY 82637.
$
28.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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