CYIA (Summer Missions) Application

Emergency Contact Information
Primary Emergency | Contact Name

First NameLast Name
Primary Emergency | Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Emergency | What is your relationship with this person?
Secondary Emergency | Contact Name

First NameLast Name
Secondary Emergency | Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency | What is your relationship with this person?

Medical Information

To be filled out by parent.guardian if applicant is under 18
Name of Insurance Company

NamePolicy #
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of last tetanus shot
Please list any of the following; medication allergies, food allergies, or chronic health concerns. (write "none' if nothing applies)

Medical Information

To be filled out by parent.guardian if applicant is under 18
The following OTC medicines will be available during training week. Please write below any medications you do not want your child to receive. Aleve/Naproxen, Ibuprofen, Tylenol, Tribiotic Ointment, Benadryl, Tylenol Sinus, Cough Elixir, Cough Drops, Imodium, Mylanta, Pepto-Bismol, Tums, Acetaminophen, Antacid Chews.
My child should not take: (leave blank if all are ok)
Please list any prescription medications your child will need to bring as well as what it is for and the dosage.

Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I understand that if the applicant is sick for over 24 hours, I will have to arrange for transportation home. In case of a medical emergency, I hereby give permission to the physician selected by the school nurse to secure proper treatment for my child as named on this form. (You will be notified as soon as possible in case of serious injury or illness.)
Photo and Video Release: Please read the release and indicate your agreement and signature below. 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.

Reference (pastor or church leader)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reference (adult friend who is not a relative)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
First-Year Missionaries: Please share how and when you came to know Jesus as your personal Savior. Returning missionaries: Please share how your previous experience with summer missions impacted your life and why you want to return.
How did you hear about this program?
Should be Empty:

General Information