View Qualifications Here Application for NEW CYIA Missionaries NEW Summer Missionary Application Packet Step 1 of 7 14% PERSONAL INFORMATION:Upload Photo(Required)Max. file size: 512 MB.Date of Application: MM slash DD slash YYYY CEF Chapter Name(Required) West Central Chapter SHOES Chapter Ohio State Greater Cleveland Chapter Akron Chapter Greater Canton Chapter MARCK Chapter Greater Columbus Chapter Miami Valley Chapter South Central Chapter Cincinnati Chapter Full Name:(Required) First Middle Last Date of Birth:(Required) MM slash DD slash YYYY Present Mailing Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone Number:(Required)Cell Phone:(Required)Email:(Required) Select T-Shirt Size: Adult Small Medium Large XL XXL Please select one T-Shirt size, Adult or YouthSelect T-Shirt Size: Youth Small Medium Large XL Please select one T-Shirt size, Adult or YouthAre you 21 Years of Age?(Required) YES NO If NO Please Indicate Your Age:(Required)Gender:(Required) Male Female Name of Parents or Guardians:(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are your parents/guardians in sympathy with your missionary purpose?(Required) YES NO If not, what is their objection?(Required)How did you become interested in the CYIA program?(Required) EDUCATION AND TRAINING:Name of Current School(Required)Latest Grade Level Completed(Required)Do you require any additional aid in learning?(Required) SPIRITUAL LIFE:Give approximate date of salvation:(Required)Name of the local Church you are connected with:(Required)How have you been involved in your local church?(Required)Your purpose for applying to the CYIA program?:(Required) EXPERIENCE:Describe any training and experience you’ve had in Child Evangelism Fellowship.(Required)Have you served in CEF® prior to this?(Required) YES NO If so, in what capacity?(Required)Name of local director under whom you served:(Required)Describe any experience you’ve had in working with children:(Required)Have you been used to lead a child or children to Christ?(Required) YES NO If yes, Describe:(Required)FOR ALL MISSIONARY CANDIDATES:I understand that Child Evangelism Fellowship will investigate my work and personal history and verify data given on this application. I authorize all individuals, schools and firms named therein to provide information about me and I release them from all liability for damage in providing this information. I certify that to the best of my knowledge all answers and information given on this application are true and correct.(Required) Signature I agree that this signature will be an electronic representation of my signature for all purposes when I use them on documents, including legally binding contracts - just the same as a wet ink signature on paper.Date(Required) MM slash DD slash YYYY CHILD EVANGELISM FELLOWSHIP®Testimony and Biographical SketchName(Required) First Last Date(Required) MM slash DD slash YYYY 1. Are you born again?(Required) YES NO What do you base your salvation on? (Give Bible Scripture references f what you base your salvation on.)(Required)2. Your spiritual growth since your conversion to Christ.(Required)3. Your practices in prayer, Bible study, church attendance, fellowship and witnessing.(Required)4. Your Christian service. How have you been serving the Lord? (e.g. Helping in Good News Club or at church with the ministry to children, etc.)(Required)5. Your standards, based on the Word of God, regarding tobacco, drugs, and alcohol. Please be specific on each of these areas – use back of sheet for more space. Please read I Cor. 6:19&20, Rom. 1, I Cor. 6:9, Rom 12:1&2 before writing your answer.(Required) Medical QuestionnaireTo be filled out by the parent or guardian, if the applicant is under the age of 18.Name of Applicant:(Required) First Last Age:(Required)Parent's Name:(Required) First Last Phone #:(Required)Emergency Contact:(Required) First Last Phone #:(Required)Medical Coverage for Applicant: Drop files here or Select files Max. file size: 512 MB. (Please make a copy of both sides of your insurance card and include file)Name of Insurance Company:(Required)Policy Number:(Required)Family Physician:(Required)Phone:(Required)Does the applicant have: (select all that apply)(Required) Diabetes Hypoglycemia Asthma Hay Fever Allergies to Medication Chicken Pox Rheumatic Fever Mumps Rubella German Measles Measles Serious Reaction to Bee Sting Has the applicant had any illness requiring a visit to the doctor in the last 3 months? (If yes, list below) Special Diet None of the Above If Yes, please explain:(Required)Has the applicant had any illness requiring a visit to the doctor in the last 3 months?(Required) Yes No If Yes, what was the health problem?(Required)Do you have any health conditions or physical challenges that would require special services?(Required) Yes No If yes, please indicate types of services you may need:(Required)Do you use an inhaler?(Required) Yes No If yes, for what problem?(Required)Do you carry an Epi Pen?(Required) Yes No If yes, for what allergic reaction?(Required)Please list any non-prescription drugs that you would allow your child to take at his/her own discretion (ie: Tylenol, Aspirin, ibuprofen, Inhaler etc.)(Required)Please list any prescription drugs being brought by the applicant: Include Inhalers or Epi pen. NOTE: All medications must be in their original containers, must be in a labeled zip lock bag, and must be turned into the CYIA Director or nurse at registration. No medication of any kind will be allowed in dorm rooms without the knowledge and approval from the CYIA Director.(Required)Name of Medication/ What is it for/ DosageI, ____________________ parent or guardian of _________________________ hereby authorize the nurse on duty and or dorm counselor or director at the Child Evangelism Fellowship® CYIA™ Training School to serve in loco parentis for me in giving over-the-counter medication to my son or daughter. I authorize the CYIA School Director, the Child Evangelism Fellowship State Director, and the nurse on duty to serve in loco parentis for me in taking my son or daughter to a doctor or emergency room for any urgent need with the understanding that the parent or guardian will be notified as soon as possible.(Required) Parent/Guardian Name Applicants Name Signed(Required) I agree that this signature will be an electronic representation of my signature for all purposes when I use them on documents, including legally binding contracts - just the same as a wet ink signature on paper. Date(Required) MM slash DD slash YYYY LIABILITY AND RESPONSIBILITY CLAUSE: Child Evangelism Fellowship is not responsible for any medical bills incurred while the CYIA missionary candidate is attending training school. I agree to use my own medical insurance as the primary coverage in the event that my student needs medical care. I understand that I, the parent or guardian, will be responsible for any medical bills for my child and will make sure all medical bills are paid for in full. I, understand this electronic signature carries the same legal weight as their pen-and-paper counterparts.(Required) Signed Date MM slash DD slash YYYY Photography and Video Release: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.Name of Child or Adult Participant: First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I agree that this signature will be an electronic representation of my signature for all purposes when I use them on documents, including legally binding contracts - just the same as a wet ink signature on paper. Signature (Parent or Guardian if a minor) Date MM slash DD slash YYYY Permission to TransportPERMISSION TO TRANSPORT TO AND FROM CYIA: I, ________________________________give permission for ___________________________ to transport my son/ daughter, ______________________________________, to CYIA training held at Mt. Vernon Nazarene University on _________________________(day of week) and return date of ___________________if I am unable to pick him or her up.Parent/ Guardian Name, Name of person(s) who can transport child to and from CYIA, Student Name, date traveling to training, date returning.PERMISSION TO TRANSPORT WHILE AT CYIA: I _____________________________ give permission for my child_________________________________ to be transported by a CEF staff member to any CYIA activities such as the 1-day club and outing on (Friday June 16, 2023) of CYIA training.(Required)Parents Name, Students NameWaiver for Minors.Permission to Transport During 5-Day Club Ministry Weeks Item number six of the Child Evangelism Fellowship (CEF®) USA Child Protection Policy fact sheet 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 in the company of only one adult of legal age. Therefore, I, the parent or legal guardian of __________________, a minor, hereby waive the above requirement for this minor and give my permission for him/her to travel and serve with Child Evangelism Fellowship without being accompanied by two or more adults at any given time. Minors Name Signature - I agree that this signature will be an electronic representation of my signature for all purposes when I use them on documents, including legally binding contracts - just the same as a wet ink signature on paper. Signature Date MM slash DD slash YYYY PARENT OR LEGAL GUARDIAN -I recognize that as with any activity involving motor vehicle transportation, there exists the potential for accidents resulting in bodily injury and/ or loss of limb or life. • We acknowledge that there exists the potential of a vehicular accident occurring while our child or children are being transported while under the care of the Drivers designated. • I, we assume the healthcare expenses relating from any such accident, illness or other incapacity which may occur while our child or children are under the care of the designated driver.• Designated drivers above has and maintains valid and adequate vehicle and liability insurance to provide an umbrella of coverage for all occupants of the transportation vehicles. Parent/ Guardian Signature - I agree that this signature will be an electronic representation of my signature for all purposes when I use them on documents, including legally binding contracts - just the same as a wet ink signature on paper. Date MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneOther person ( relationship) and phone number to contact in case of emergency.
