CYIA WI Staff Application

{name}
Medical & Emergency Contact Information
First & Last Name of an Emergency Contact *
Relationship*
Personal Phone for Emergency Contact*
Area code and number
Work Phone for Emergency Contact*
Area code and number
Alternate Contact in case first person is unavailable.
Alternate Emergency Contact First & Last Name *
Relationship*
Alternate Contact's Phone number
All medication (prescribed and/or over-the-counter) must be kept in the original, labeled containers and turned in to the CYIA nurse upon arrival. Do NOT bring any over-the-counter that you do not take regularly as those are available at CYIA.

If you list any prescribed/regularly used medication, a form will be sent to you prior to training to be completed and turned in at registration. Those sleeping in the cabins with the summer missionaries (minors) need to have the nurse keep their medication. This includes vitamins, supplements and over the counter medications. Be sure they are in their original container.

For the health and safety of all, we request that anyone with a communicable disease NOT be sent to training. We appreciate your cooperation and understanding in the matter of public health.
Prescribed medication or vitamin supplements taken regularly*
Note specific allergies
Note any other health difficulties
Last Tetanus Booster Date

MonthDayYear
Date
Tetanus Booster shot.

If a date is not listed, in the event of an injury, you may receive a booster injection at your own expense.
Do you have Health Insurance Coverage*
Health Insurance Company
Policy 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. If a minor, a parent or guardian signature is required.*

{name}
Confidential Screening Form
Child Evangelism Fellowship Child Protection Policy

CEF takes seriously our responsibility to protect the children we serve, the volunteers who serve the children, our partnering churches and the good name of Jesus Christ.

Following are some important considerations for all who will volunteer and have direct contact with the children through CEF ministries.

CEF does online background checks and volunteer applications utilizing a secure server so that your information is safe.
All workers (volunteer or paid) must review the Child Protection Policy and view the "Protecting Today's Child" presentation annually
All workers (age 18 and older) are required to undergo a national criminal background check.
Approved workers will issued a required nametag to be worn during all CEF sponsored activities.
If you turn 18 during the summer, please make sure that your local contact gives you more information about this screening.
If you are under 18, please include accurate contact information for the references.
If you have not viewed the Protecting Today's Child Presentation, you can do it now. This is to be done annually.
I, {name}, have signed the Ministry Compliance Agreement in this calendar year*

YesNo
Please view the video, review the Worker Compliance Agreement and Statement of Faith. Check each in the Policy Agreement section.
Review the following
Child Protection Policy Agreement. Check to indicate agreement with the following statements*

My agreement with the Statement of FaithI will abide by the above Ministry Compliance AgreementI will abide by the Child Protection policies of CEF as long as I am actively involvedI have reviewed the Protecting Today's Child Presentation in the last 12 months
Has CEF of WI done a background check on you since your 18th birthday?*

YesNoN/A
Approximate date Background check was last run

MonthDayYear
Date

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References & Background Check

Child Protection Policy requires us to do references checks as well as background checks on all staff members because it is an overnight activity. A minimum of two references must be received. We are asking for four, in order to ensure receiving the required amount. A reference from your pastor/church leader or someone who know of your spiritual journey is required. The others are personal acquaintance or employers. These are not to be relatives.
Church Leader (to be used as reference)*

First NameLast Name
Church Leader Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Church Leader's Phone Number
Church Leader's Email Address*
example@example.com
Best Way to Contact your Church Leader reference

TextEmailPhoneOther
Reference # 2 - Christian adult
Reference #2 Name*

First NameLast Name
Ref # 2 Phone Number
Reference #2 Email Address*
example@example.com
Reference #3 - Christian adult
Reference #3 Name*

First NameLast Name
Ref # 3 Phone Number
Reference #3 Email Address*
example@example.com
Reference #4 - Christian adult or employer if applicable
Have you been employed by this person?

YesNo
Reference #4 Name

First NameLast Name
Ref # 4 Phone Number
Reference #4 Email Address
example@example.com
Personality

In each of the next twelve boxes, select the best word that describes you.
1
2
3
4
5
6
7
8
9
10
11
12
Background Check Form*

I have submitted the background check form.I have not completed the background check authorization
Background Check - If you have not completed the background check authorization, please explain.

Rows	Agree	Disagree
Respect one another, students and staff
Comply with directions and rules given
Maintain a high dress code standard
Abstain from use or possession of alcohol, drugs and tobacco
Allow your photograph/video to be used for promotional purposes
Believe the CEF Statement of Faith
Comply with Child Protection Policy

Rows	Attend	Not Able to attend
Orientation (in May in your area)
CYIA Training - Camp Fairwood (June 10-17)
CYIA Training - Local Chapter (Determined by your chapter)

Wisconsin CYIA™ Staff Application

Contact Information

Medical & Emergency Contact Information

References & Background Check

Personality

Position Descriptions

Commitment and Intent