Medical Release and Permission Form

CHILD EVANGELISM FELLOWSHIP OF IOWA INC.

Christian Youth In Action® (CYIA®)

PO Box 5095, 4700 Gordon Drive, Suite 220, Sioux City IA 51102

Beth Lamb/State Director 712-274-6217 website: cefofiowa.org

Child Evangelism Fellowship of Iowa, Inc.

Summer Missionary Application

Age: All applicants must be at least fourteen (14) years of age (unless approved by Local Coordinator), on or before the beginning of the CYIA Training School.
All applicants must be saved at least one year, and be mature and experienced sufficiently to perform without problems.
Attitudes: All applicants must be able to sign the Statement of Faith, the Doctrine Policy, and completely fill out all Child Protection Policy Forms.
All applicants must agree to follow and abide by all policies and leadership of Child Evangelism Fellowship. Theymust be willing to submit to the Training Director and all staff.

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Being a CYIA Summer Missionary means hard work. You must be willing to learn and study your Bible Lessons, and to accept constructive criticism from your leaders.

This summer will be rewarding, but you must also pray and consider the hard work and sacrifices you will face in accepting your task as a CYIA Missionary.

While attending the CYIA training, you must agree to abide by regulations set forth in the standards of conduct and the dress code and to conform to its fundamental standards of honor. Please be awarethat CEF may request the withdrawal of any trainee who, in the opinion of the staff, does not abide by the regulations set forth.

CHILD EVANGELISM FELLOWSHIP OF IOWA INC.

Christian Youth In Action® (CYIA®)

PO Box 5095, 4700 Gordon Drive, Suite 202, Sioux City IA 51102

Beth Lamb/State Director 712-274-6217 website: cefofiowa.org

CYIA Training & Employment Application – 2017

Name ______

LastFirstMiddleNickname

Address ______Phone (______) ______

Street

______Date of Birth ______/ ______/ ______

CityStateZip

Current Grade in School ______Email Address: ______

School Name (please indicate if you are home educated) ______

T-Shirt SIZE: ______

Parent or Guardians’ Names ______

Parent or Guardians’ Work Phone ______Cell Phone ______

Work Phone ______Cell Phone ______

Name of your Church ______Phone ______

Church Address ______

______

Pastor’s Name ______

Youth Pastor’s Name ______

Personal References – Please include four people - 1. Your Pastor or Youth Pastor; 2. Your Youth leader or

Sunday School teacher; 3. Another adult who knows you well (could be a school teacher) and 4. A friend.

NameAddressCity/St/ZipPhone

Be sure to include a photo of yourself with the application, and a $50 application processing fee. Application MUST be returned by April 1, 2017 to:

Listed below are statements concerning your conversion and Christian life.

Tell how and where you were saved – Your testimony (feel free to use the backside of this page.)

______

Your Christian experiences: ______

______.

A verse of Scripture and how it has helped you in your Christian walk: ______

______

State why you are interested in evangelizing children: ______

______.

Why are you attending this Summer Missionary Training?

______.

List special training and abilities:

______

______What teaching experiences have you had? (Sunday School, VBS, AWANA, etc.)

______.

What leadership experiences have you had?

______.

Any other information that you would like us to know?

______.

Missionary covEnAnt

If chosen as a summer missionary for Child Evangelism Fellowship (CEF®), would you be willing to:

ٱ Yes ٱ NoWork with another person or a team that may be assigned to you?

ٱ Yes ٱ NoSend weekly reports to your director for the work that you have completed each week?

ٱ Yes ٱ NoFollow directions of those in authority over you?

ٱ Yes ٱ NoTeach clubs that your director will schedule for you, according to your availability, as you indicate below.

Check the weeks that you will be available to teach. – Clubs will be scheduled for you according to the following weeks that you check below.

( ) June 19-23 ( ) July 10-14 ( ) July 24-28 ( ) August 7-11 Camp Good News, Elementary

( ) June 26-30 ( ) July 17-21 ( ) July 31-Aug 4 ( ) August 13-17Camp Good News, Middle School

Do you have a driver’s license? YES or NO

Is there someone in your family or church who would assist with transportation? YES or NO

If yes, name and phone number ______

Names and ages of your siblings ______

I understand that:

1.I must successfully complete the 1 day of pre-training PLUS 9 days of statewide CYIA training.

My final and complete acceptance as a trained summer missionary depends on my conduct, cooperation, ability to learn, and zeal as exemplified during the training period, including the pre- and post-training.
I have read and agree to abide by the general rules and standards as outlined in the CYIA Guidelines.
I have read and signed the Statement of Faith and Doctrinal Protection Policy.
I have completed this application and verify that the information is current and accurate.

______

Student’s SignatureDate

______Parent or Guardian’s Signature Date

Medical Release and Permission Form

Effective dates: January 1-December 31, 2017

To be completed by parent/guardian

Personal Information Please print in ink.

Name: ______

LastFirstMI

Age: ______Date of Birth: ____/____/____ Grade in school: ______Sex: M ___ F ___

Home Address: ______

City: ______State: ______Zip: ______E-mail: ______

Home Ph.: (______) ______Student Cell Ph.: (______) ______

Mother’s Name: ______

Day Ph.:(____)______Evening Ph.:(____)______Cell Ph.:(____)______

Father’s Name: ______

Day Ph.:(____)______Evening Ph.:(____)______Cell Ph.:(____)______

Emergency contact person: ______Relationship:______

Day Ph.:(____)______Evening Ph.:(____)______Cell Ph.:(____)______

Medical Insurance Company: ______

Policy#:______Subscriber: ______

Physician:______Office Phone: (_____) ______

Dentist: ______Office Phone: (_____) ______

Over-the-Counter Medications

Carefully review the following list of over-the-counter medications that will be kept on hand for medical needs while at CYIA. These items will be given out by a staff member only if necessary. Circle any that you do not want your child to have.

Tylenol

Ibuprofen

Midol

Aspirin

Zyrtec

Cough drops

Cough Syrup

Benadryl

Sudafed

Calamine Lotion

Neosporin

Antacid Tablets

Anti-itch Crème

Rubbing Alcohol

Hydrogen Peroxide

Pepto-Bismol

Band-Aids

Medical History

Check the following areas of concern for your child. If necessary, add another page with details.

Date of last tetanus shot: ______
Does your child wearGlasses? ______Contacts? ______
Does your child suffer from, ever experienced, or is currently being treated for any of the following?

____ Asthma ____ Epilepsy____Heart Trouble____ Diabetes

____Headaches ____Physical Handicaps _____Frequently Upset Stomach ____ADHD_____ADD ____Depression _____Lime Disease

Please explain:

Does your child have any learning challenges that we need to be aware of to help him/her be successful at CYIA training (if attending)? Please Explain:

Does your child have allergies to?

____ Pollens____ Medications ____ Food____ Insect Bites

Please explain:

Please list any major illnesses your child has experienced during the last year.

Please list all medications your child iscurrently taking and the reason for taking medications. Explain.

Should your child’s activities be restricted for any reason? If so, please explain.

Parental Permission Form

I/We give permission to use photos of my/ourchild for our CEF Ministry publicity.

I/We the undersigned have legal custody of the child named above, a minor, and have given our consent to him/her to attend Christian Youth in Action 2016 and other CEF activities throughout the year.

I/We acknowledge that all pertinent information concerning any medical, emotional or learning challenges have been made known that possible could affect my child’s involvement in the ministry of CEF.

I/We understand that there are inherent risks involved in any ministry, or recreational/athletic event, and I/we hereby release Child Evangelism Fellowship, its employees or volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement.

In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by CEF, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising form the giving of such consent.

I/We also acknowledge that I/we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the child named above.

I/We also agree to bring my/our child home at my/our own expense should they become illor if deemed necessary by the CEF staff member.

Signed: ______Print Name: ______Date:______

Parent/Guardian

Reference Report

Child Evangelism Fellowship of Iowa, Inc.

Phone: E-mail:

Please complete both sides and return in the self addressed envelope.

Applicant’s Full Name ______is applying to Child Evangelism Fellowship to serve as a Christian Youth in Action® Missionary.

The applicant has listed you as a reference. Your personal evaluation and recommendation gives insight into the character of the applicant that would be very helpful in determining the applicant’s ability to perform this responsibility. Please be candid and objective.

 How long have you known the applicant? ______In what relationship?______

 How well do you know the applicant? (Circle one)CasuallyWellVery well

 Is there any reason known to you that the applicant should not work with children? YesNo

If yes, please explain______

 Applicant’s relationship with others, generally (circle one) Poor Fair Good Very Good

Applicant’s attitude toward authority (circle one) Poor Fair Good Very Good

Applicant's ability to work with others (circle one) Poor Fair Good Very Good

Applicant's work ethic when working alone (circle one) Poor Fair Good Very Good

 What are the applicant’s strong points and special abilities? ______

______

What are the applicant’s challenges? ______

______

What is the applicant’s general outlook on life? (Circle one) Negative Neg/Pos Positive

 Is the applicant active in the church? ______If so, in what capacities? ______

______

 Are you aware of any unbiblical sexual tendency in the applicant? ______If yes, please comment.

______

 How do you rate this applicant’s potential for ministry? (Circle one) Average Good Superior

 Would you recommend that we accept this applicant? (Circle one) No Questionable Yes

Additional Comments:______

CHARACTER TRAIT EVALUATION / U
N
K
N
O
W
N / P
O
O
R / 1 / 2 / 3 / 4 / 5 / E
X
C
E
L
L
E
N
T / Comments to characteristics
Communications Skills
Relationship Development
Confrontational Skills
Tactfulness/Sensitivity
Drive/Initiative
Mental Alertness
Consistent Spiritual Walk
Bible Knowledge
Sense of Call or Mission
Submission to Authority
Self-respect
Freedom From Worry
Self-Discipline
Conscientiousness
Perseverance
Good Judgment
Flexibility
Decisiveness/Follow-through
Servant Spirit
SCORING / 1 / 2 / 3 / 4 / 5 / For Office Use Only

Signature: ______Date: ______

Printed Name: ______Occupation: ______

Address: ______

City: ______State: ______Zip: ______

Daytime telephone: ( ______) ______- ______

E-mail address: ______

Reference Report

Child Evangelism Fellowship of Iowa, Inc.

Please complete both sides and return in the self addressed envelope.

Applicant’s Full Name ______is applying to Child Evangelism Fellowship to serve as a Christian Youth in Action® Missionary.

 How long have you known the applicant? ______In what relationship?______

 How well do you know the applicant? (Circle one)CasuallyWellVery well

 Is there any reason known to you that the applicant should not work with children? YesNo

If yes, please explain______

 Applicant’s relationship with others, generally (circle one) Poor Fair Good Very Good

Applicant’s attitude toward authority (circle one) Poor Fair Good Very Good

Applicant's ability to work with others (circle one) Poor Fair Good Very Good

Applicant's work ethic when working alone (circle one) Poor Fair Good Very Good

 What are the applicant’s strong points and special abilities? ______

______

What are the applicant’s challenges? ______

______

What is the applicant’s general outlook on life? (Circle one) Negative Neg/Pos Positive

 Is the applicant active in the church? ______If so, in what capacities? ______

______

 Are you aware of any unbiblical sexual tendency in the applicant? ______If yes, please comment.

______

 How do you rate this applicant’s potential for ministry? (Circle one) Average Good Superior

 Would you recommend that we accept this applicant? (Circle one) No Questionable Yes

Additional Comments:______

Signature: ______Date: ______

Printed Name: ______Occupation: ______

Address: ______

City: ______State: ______Zip: ______

Daytime telephone: ( ______) ______- ______

E-mail address: ______