CYIA Pre-Training Registration
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Age
*
Date of Birth
-
Month
-
Day
Year
CEF Chapter
*
Please Select
Benton
Capitol
Coos
Curry
Evergreen
Greater Portland
Jackson
Josephine
Klamath-Lake
Lewis & Clark
Lincoln
Linn
Mid-Columbia
Oregon Trail
Polk
Ponderosa
Portland Westside
Umatilla
Umpqua
What CYIA level have you completed?
*
Please Select
Never attended
Level Blue
Level 1
Level 2
Level 3
Level 4
Level 5
Gender
*
Please Select
Male
Female
Shirt Size
*
Please Select
X-Small
Small
Medium
Large
X-Large
XX-Large
XXX-Large
How did you hear about CYIA Pre-Training?
Do you have any allergies?
*
Yes
No
If "Yes", please list.
Emergency Contact
*
Name
*
Phone Number
Insurance
*
Company
*
Policy #
Do you have any medical conditions?
*
Yes
No
If "Yes", please describe.
Photo/video release (Parent if under 18)
*
I give CEF permission to use photos and videos taken of me for advertising, educational, and/or promotional purposes.
Transportation release (Parent if under 18)
*
I understand there may be occasions when I may be traveling from location to location in the company of only one CEF vetted and background checked adult of legal age. I give my permission to travel and attend Fall Retreat (a ministry of Child Evangelism Fellowship) without being accompanied by two or more adults at any given time.
Payment ($25)
*
Cash/Check
Venmo/Zelle
Scholarship
Signature (Parent if under 18)
*
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: