Jr. Christian Youth in Action

Jr. Christian Youth in Action - 2025 Application
Jr. CYIA Student

Basic Information
Name of Applicant*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
CYIA Student
Birthdate

MonthDayYear
CYIA Student
Primary Phone Number*
Phone Number Type*
T-Shirt Size
CYIA Student
Parent/Guardian #1 - Contact Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Parent/Guardian #1
Primary Phone Number Type*
Secondary Phone
Parent/Guardian #1
Secondary Phone Number Type
E mail*
Parent/Guardian #1 (example@example.com)
Parent/Guardian #2 - Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Please enter a valid phone number.
Primary Phone Number Type
Parent/Guardian #2
Secondary Phone
Parent/Guardian #2
Secondary Phone Number Type
Parent/Guardian #2
E mail
Parent/Guardian #2 (example@example.com)
Emergency Contact Information - Alternate Pickup/Release
Emergency Contact #1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Phone Number Type
Emergency Contact #1
E mail
Emergency Contact #1 (example@example.com)
Relationship to Applicant
Emergency Contact #2 *

First NameLast Name
Phone Number*
Please enter a valid phone number.
Phone Number Type
Emergency Contact #2
E mail
Emergency Contact #2 (example@example.com)
Relationship to Applicant

	Information
High School Name
Current Grade Level
College Name
College Grade Level, Degree
Employment Status

	Reference Information.
Full Name
Church
Phone Number
Email
Address

	Reference Information.
Full Name
Church
Phone Number
Email
Address

	Reference Information.
Full Name
Church
Phone Number
Email
Address

Parent/Guardian Agreement & Consent
I understand that my teen is expected to attend a CYIA™ pre-training with the local CEF Chapter prior to CYIA. The date and location for this pre-training will be communicated by my Local Director/Coordinator. I also understand that my teen will teach/assist at least two weeks of 5-Day Clubs after Jr. CYIA training is completed or the equivalent as determined by my local CEF Director. DEPOSIT FEE of $25.00 must accompany this application and is non-refundable. The remaining $115.00 for training will be due by April 15, 2024. The deadline to submit this application is March 28, 2025.*

YesNo
I, the undersigned parent, herby release, discharge, indemnify, hold harmless and defend CEF of Missouri, its officers, employees and servants from any and all liability (claims, demands, losses, causes of action, suits and/or judgements) of any kind that I or my family may have against CEF of Missouri due to death, personal injury or illness, loss or damage to property, or future causes that occur during the CEF of Missouri Jr. CYIA training. In the event of a medical emergency, I authorize CEF of Missouri to secure medical care deemed necessary for the participant.*

YesNo
Name of Parent/Guardian
Signature of Parent/Guardian*

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Application Deposit - $25.00 non-refundable

CYIA Application DepositCYIA application deposit (non-refundable)

$25.00 Quantity

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Medical Insurance Disclaimer

Only complete this page if you are NOT COVERED BY ANY HEALTH INSURANCE
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
I do not have medical insurance and will not hold Child Evangelism Fellowship and/or any of their departments, partnerships, churches, officers, volunteers, agents, employees, and affiliates responsible for covering any expenses incurred due to accident, injury, or illness.
Name of Parent/Guardian
Date

MonthDayYear
Date
Signature of Parent/Guardian

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PHOTOGRAPHY & VIDEO RELEASE

CYIA of Missouri
Child Evangelism Fellowship® may, from time to time, document the activities of the ministry with photographs 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.
Name of Student or Adult Participant*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E mail*
Parent/Guardian #1 (example@example.com)
Name of Parent/Guardian*
Date*

MonthDayYear
Date
Signature of Parent/Guardian*

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WAIVER FOR MINORS

CYIA of Missouri
Trainee's Name*

First NameLast Name
The Child Evangelism Fellowship® (CEF®) USA Child Protection Policy 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 and/or serving in the company of only one adult of legal age. Therefore, I, the parent or legal guardian of the named student, a minor, hereby waive the above requirement for this minor and give my permission for him/her to travel and serve with his/her teammates participating in the ministries of Child Evangelism Fellowship, without the presence of an additional adult or minor.
Name of Parent/Guardian*
Date*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Signature of Parent/Guardian*

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CODE OF CONDUCT

CYIA of Missouri
The following rules are designed to help us live well in a close community setting while at Training School and back in your local chapter. At all times conduct should put others first and also bring honor and glory to the Lord Jesus Christ. Failure to
adhere to the Code of Conduct may result in disciplinary action including being sent home from Jr. CYIA Training School if needed. Following these rules will help our time at Training School to go as smoothly as possible for everyone!

Generally speaking, the following attitudes should be representative of your words and actions…
• Respect for authority and those you will be working with
• Punctuality related to all clubs
• Cleanliness in your personal appearance
• Honesty in your conversations and interactions with others
• Diligence in your studies and well-prepared for your part of teaching in each club

The following specific rules should also be followed…
1. Dress Code: The dress code must be followed at all times.
2. Complete all required assignments in class or at home.
3. Relationships: Friendships with Christians of the opposite sex are beneficial in social, spiritual and leadership development. Therefore, you may talk, walk, sit, and eat with members of the opposite sex, but at no time will any “pairing-off” with them be acceptable.
4. Name tags: Wear YOUR name tag at all times (other than recreation)
Should be Empty:

	YES	NO
Asthma
Hay Fever
Epilepsy

	YES	NO
Chicken Pox
Rheumatic Fever
Mumps
Rubella (German Measles)
Measeles
Serious reaction to bee stings

	YES	NO
Diabetes
Hypoglycemia

	YES	NO
Aleve/Naproxen
Benadryl
Imodium
Orajel
Ibuprofen
Tylenol Sinaus
Mylanta
Tears
Tylenol
Cough Elixir
Pepto-Bismol
Acetaminophen
Tribiotic Ointment
Cough Drops
Tums
Antacid Chews

	Name of Medication	What it is for	Dosage
Medication
Medication
Medication

Jr. Christian Youth in Action - 2025 Application

Jr. CYIA Student

Parent/Guardian #1 - Contact Information

Parent/Guardian #2 - Contact Information

Emergency Contact Information - Alternate Pickup/Release

CYIA Student

References

Spiritual Life

Experience

Parent/Guardian Agreement & Consent

Payment Methods

Medical Insurance Disclaimer

Medical Questionnaire

PHOTOGRAPHY & VIDEO RELEASE

WAIVER FOR MINORS

CODE OF CONDUCT