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Sponsored by:
Child Evangelism Fellowship of East Texas, Inc.
Instructions
Step 1: GIVE the appropriate Confidential Reference Questionnaires to those you have indicated on your
application. Be sure to also provide an envelope that has the address to which the reference is to be returned.
Discuss with your parents/guardians your desire to be a part of CYIA. Ask them to read and
complete the Parent/Guardian Reference Questionnaire.
Youth Leader Reference should be completed by your youth leader who knows you best.
The Teacher/Coach/Employer Reference goes to a teacher, coach or employer who knows you well.
Step 2: FILL out your application completely and photocopy it for your own records.
Step 3: READ Statement of Faith and SIGN Doctrinal Protection Policy (Read and discuss with parents.)
Step 4: FILL out and SIGN the Background Check Authorization form.
Step 5: MAIL:
 Completed application
 Signed Doctrinal Protection Policy form
 Signed Background Check Authorization form
 Completed Medical form
 Other forms
Please return application and forms to:
CEF Capital Country
PO Box 66761
Austin, TX 78766-6761
Your application cannot be processed until all parts have been received. Application does not mean
acceptance. Your application will be treated confidentially and read only by individuals directly
involved in your application decision and appropriate leadership. Therefore, please thoroughly complete
the application with honest, straightforward responses. Our hope is that this process will be a means for
you to get to know yourself better, to be encouraged as you are reminded of your gifts and strengths, and to
be motivated to grow in those areas that need development.
Step 6: ASK the Lord to supply the necessary finances.
Rev. 2012
Sponsored by:
Child Evangelism Fellowship of East Texas, Inc.
Thank you for applying for CYIA. Your thoroughness in completing this
application is appreciated. Please print neatly.
(Full Legal Name) First
M
F
Middle
Last
_________________________________________
Nickname (Name you go by if different from first name)
Street Address / Apt. #
City/ State/ Zip
Home Phone
Cell Phone
E-mail
Birth Date
Age
Are you a U.S. citizen? Yes
T-Shirt Size: S
Social Security Number
No
M L XL XXL XXXL
PERSONAL INFORMATION:
Year in School: Fresh. Soph. Jr. Sr.
Name of School
Graduation Year
List the activities in which you are involved (clubs, athletic teams, drama, music, etc.).
Briefly describe your relationship with your family or the people with whom you live.
Why do you want to participate in CYIA?
CHRISTIAN EXPERIENCE:
Write a brief statement of when and how you came to know Christ personally as
your Savior. (Attach additional sheet if you need more room.)
Please describe how are you growing in your relationship with
Christ. (Attach additional sheet if you need more room.)
How often do you spend regular time alone with the Lord in Bible study and prayer? (circle one)
1
2
3
4
5
6
7
days/week
Please describe how you have seen God working in
your life. (Attach additional sheet if you need more
room.)
Are you involved in a local church?
Name of Church
Any other Christian group? (ex. Awana, Young Life, etc.)
Name of Group
What main points of the gospel you would share with someone who wanted to become a
Christian? (Attach additional sheet if you need more room.)
Rev. 2012
PAGE 2
Do you believe children should be given opportunity to receive Jesus as Savior? Yes No
PAGE 3
Can you conscientiously and without reservation sign the Statement of Faith and the Doctrinal Protection Policy?
Yes No
Have you accepted Jesus Christ as your personal Savior? Yes No
CONFIDENTIAL INFORMATION
Your parent/guardian must read these questions and give consent for you to answer them by signing below. This
section is required for consideration of your application. Please answer the following questions honestly. This
information will be treated confidentially and will be seen only by individuals directly involved in your application
decision and by appropriate project leadership.
I have read these questions in the Confidential Information section and give my consent for my son/daughter to answer.
Parent Signature
Date
Are you dating someone who plans to participate in CYIA? Yes No
If yes, who?
Do you drink alcoholic beverages? Yes No
If yes, how frequently?
Do you smoke or use tobacco products? Yes No
Have you ever used narcotics, hallucinogens or drugs not prescribed by a doctor? Yes No
Have you ever been convicted of a crime? Yes No
Have you ever received counseling or treatment for mental or emotional health? Yes No
In the past 12 months, have you struggled with eating disorders or depression? Yes No
In the past 12 months, have you had a relationship or been involved in an activity that would not be considered “above
reproach”? Yes No
If “yes” to any of the above questions, please explain and give date of last occurrence:
GENERAL HEALTH
How is your general health at this time?
Do you have any physical problems that might require attention while attending the:
13 Day Camp Session? Yes No
(If so, please explain below.)
During the summer ministry? Yes No
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
CYIA GUIDELINES
PAGE 4
Are you willing to follow CEF guidelines for the Training School/Summer Ministry and CEF leadership even though
you might not totally agree with them in every situation? Yes No
How would you respond to your leadership if you disagreed with them?
CYIA Training School/Summer Ministry will have standards of dress, conduct, and accountability. Are you willing to
adhere to these standards with a positive attitude? Yes No
Do you understand that you must be available to teach 5-day clubs during the summer? Yes No
Please list the weeks you will not be available to teach:
By signing below, I acknowledge that I have provided, to the best of my knowledge, information that is true and
accurate.
Signature
Rev. 2012
Date
Applicant’s Name______________________________________________
Please ask each person to complete the appropriate reference form and return it to you in a sealed envelope for you to send with your completed
application. (You can check the box when you have given the form to the appropriate reference.)
 Youth Leader
Full Name: First Last
Home Phone Work or Cell Phone
E-mail
 Teacher, Coach or Employer
Full Name: First Last
Home Phone Work or Cell Phone
E-mail
 Parent / Guardian
Full Name: First Last
Home Phone Work or Cell Phone
E-mail
APPLICATION CHECKLIST
All required documents must be turned in before your application can be reviewed.
 Completed application (keep photocopy for yourself)
 Signed Doctrinal Protection Policy
 Completed Background Check Authorization Form
 Completed Medical form
_________________________________________________________________________________
For office use only
Received:
 Application
 Notarized Medical Form
Application Fee
Youth Leader Reference
Teacher, Coach or Employer Reference
Parent/Guardian Reference
Medical Form Sent
CYIA Pre-Training Manual
 Confidential Screening Form and Background Check Authorization sent (if 15 or older)
Signed Doctrinal Protection Policy
Confidential Reference Questionnaire
Youth Leader
This questionnaire is to be completed by a youth leader who knows the applicant well. The purpose of CYIA is to train teenagers to effectively
share the message of salvation with children and to lead 5-Day Clubs. Because this reference is used for acceptance, it is most valuable when filled
out objectively. Please avoid the temptation to make the applicant appear perfect. Be assured that your reference will be held in strict confidence.
Please return the completed reference form in the envelope provided.
Applicant Name
Applicant Phone
Reference Name
Ministry or Church Name
Address
City
Phone
State
Zip
Email
In what capacity have you known the applicant?
For How Long?
How well? Very well
Well 
Not well Almost not at all
Signature
How have you observed this student demonstrate faith in Christ as Savior?
How have you observed this student grow in his/her relationship with God?
Rev. 2012
Date
CHARACTER TRAITS
Consistent evidence of a Christian life
(demonstrates fruit of the Spirit)
Consistent application of Biblical principles to his/her life
Flexibility (adjusts well to change)
Perseverance (moves ahead in the face of
adversity)
Responsibility (carries out duties and
obligations)
Never
Rarely
Sometimes
Frequently
Always
To what extent do these traits appear
in the student’s life?
Not Known
Excellent
Above Avg.
Average
Below Avg.
Poor
Not Known
Please check the
appropriate space for
each characteristic.
Youth Leader page 2
Critical (Negative Attitude & Sarcasm)
Tendency to Argue
Defensiveness
Moodiness
Procrastination
Irritability
Rebellion
Ability to handle pressure
Depression
Self Confidence
Anger
Works well with others
Humility
Ability to handle conflict constructively
Responsibility
Ability to communicate (presents
thoughts clearly/logically)
Servant
Sensitivity to others’ needs/feelings
Self motivation / initiative
Ability to make decisions
PLEASE ANSWER THE FOLLOWING:
Comment on the student’s relationship with his/her peers:
Does the student relate appropriately (in dress, speech, physical
contact) to the opposite sex? Yes No
If no, please explain:
What are the student’s greatest strengths and abilities?
To your knowledge, does the student struggle with an eating disorder or depression? Yes No
If yes, please explain:
Overall, how would you evaluate this student’s level of social &
emotional maturity?
To your knowledge, has the student been involved in alcohol or
drug abuse? Yes No
If yes, to what extent and how long ago?
Please list any other comments or concerns:
Rev. 2012
Confidential Reference Questionnaire
Teacher/Coach/Employer
This questionnaire is to be completed by a teacher, Coach or employer who knows the applicant well. The purpose of CYIA is to train teenagers to
lead 5-Day Clubs. Because this reference is used for both acceptance and development, it is most valuable when filled out objectively. Please avoid
the temptation to make the applicant appear perfect. Be assured that your reference will be held in strict confidence. Please return the completed
reference form in the envelope provided.
Applicant Name
Applicant Phone
Reference Name
School or Company Name
Address
City
Phone
State
Zip
Email
In what capacity have you known the applicant?
How well? Very well
For How Long?
Well Not well Almost not at all
Signature
Date
Flexibility (adjusts well to change)
Perseverance (moves ahead in the face of
adversity)
Critical (Negative Attitude & Sarcasm)
Tendency to Argue
Defensiveness
Responsibility (carries out duties and
obligations)
Moodiness
Punctuality
Procrastination
Irritability
Integrity
Rebellion
Ability to handle pressure
Depression
Self Confidence
Anger
Works well with others
Humility
Ability to handle conflict constructively
Responsibility
Ability to communicate (presents
thoughts clearly/logically)
Servant
Sensitivity to others’ needs/feelings
Self motivation / initiative
Ability to make decisions
Rev. 2012
Never
Rarely
Sometimes
Frequently
Always
To what extent do these traits appear
in the student’s life?
Not Known
Excellent
Above Avg.
Average
Below Avg.
Not Known
Please check the
appropriate space for
each characteristic.
Poor
CHARACTER TRAITS
Teacher/Coach/Employer page 2
Please comment on the applicant’s ability to make
decisions and follow through on them.
Overall, how would you evaluate this person’s level
of social & emotional maturity?
What are the applicant’s greatest strengths and
abilities?
How does the applicant respond to designated
authority and standards?
How does the applicant relate to his/her classmates,
co-workers or peers?
Describe the level of supervision the applicant
requires as a student or employee.
Please describe how the applicant has responded in
resolving conflict with you or another person.
What is the applicant’s overall attitude in the
classroom or on the job?
Rev. 2012
Please add any additional comments that you would
like to mention about the applicant.
Confidential Reference Questionnaire
Parent/Guardian
THIS QUESTIONNAIRE IS TO BE COMPLETED BY A PARENT OR GUARDIAN OF THE APPLICANT. CYIA is designed to help teenagers develop positive
character traits, leadership skills, and most importantly the practical skills necessary for the 5-Day Club. (Teaching Bible lesson, sharing the
gospel effectively, etc.) Since you know your child better than anyone else, your insights will be extremely valuable in making this the best
possible experience for him/her. Therefore, please be objective in completing this form, and avoid the temptation to make the applicant appear
perfect. Be assured that your reference will be held in confidentiality. Please return the completed reference form in the envelope provided.
Applicant Name
Parent/Guardian Name
Address
Phone
We have discussed our son’s/daughter’s plan to participate in CYIA.

We have encouraged our son/daughter to participate.

We are not opposed to our son/daughter going, but we have the following reservations:
Signature
Date
Please answer the following:
What goals do you have for your child that you hope CYIA will help develop?
What do you think will be the main contribution of your son/daughter to CYIA?
What are the greatest strengths and abilities of your son/daughter (e.g. character, skills, habits)?
Rev. 2012
Parent/ Guardian page 2
How does your son/daughter respond to constructive criticism, instruction or advice from you or another
person in authority (comply, resist, have a critical attitude, etc.)?
Comment on your child’s ability to establish healthy friendships with peers.
Briefly describe his/ her relationship with:
Mother
Father
Siblings
How does your son/daughter respond to difficult circumstances (e.g. withdraw, cling to others)?
To your knowledge, does your son/daughter struggle with an eating disorder or depression,
drug or alcohol abuse, or other physical or emotional concerns?  Yes  No
If yes, please explain:
Please add any additional comments you would like to share.
DRIVING
Will your teen be driving him/herself this summer for CYIA (including summer 5-Day Clubs in their area, but
possibly including or excluding Camp at Gospel Lakes Ranch)? Yes No
If under 18, parent must sign giving authorization for you to drive:
I,
, the parent/guardian of
who is
my son/daughter, authorize him/her to drive to and from scheduled 5-Day Clubs. I realize I take full
responsibility for my son/daughter driving him/herself and in no way will hold CEF liable should he/she
become involved in an accident. I also take full responsibility of providing the necessary auto insurance.
Signature of Parent/Guardian
Rev. 2012
Date
®
CEF CONSENT AND
RELEASE FORM
I, the undersigned parent(s) or guardians(s), hereby consent to my teen,
participating in CEF summer ministries. I give my permission for my teen to
be transported to and from
this and any corresponding event by the CEF staff or volunteers.
If my teen has medical conditions which may be relevant to a physician in
the event of an emergency, I have listed them below. In the event that an
emergency occurs, I may be reached at the telephone number listed below. If
I cannot be reached within a reasonable period of time, as determined by the
CEF sponsors, I hereby authorize the sponsors to make emergency medical
decisions for my teen. If there are any activities I do not want my teen to be
involved in I have listed them below. I am aware of the religious nature of
this event.
I understand and agree to assume all of the risks which may be encountered
during these events and irrevocably and unconditionally release and
discharge Child Evangelism Fellowship, Gospel Lakes Ranch, and its
agents, employees, and volunteers from any and all liability, actions, causes
of actions, claims, expenses, obligations and damages of any nature
whatsoever, which I now have or which may arise in the future, in
connection with the described activity or associated activities, including, but
not limited to, any injury to my child.
I state that I have carefully read and understand the foregoing release and
know the contents hereof and I
sign this release as my own free act. I understand that this is a legally binding
agreement.
MEDICAL
INFORM
ATION
Please fill out,
sign & date
this form so we
can meet any
special needs
your child has
& so we have
enough
information in
case of an
emergency.
PERSONAL
INFORMATI
ON
Name of Child
Birthday
/
/
Sex
M / F * Age
Medical conditions to be aware of:
Physical restrictions:
Hair color
Instructions and medications:
Height
Weight
Date of last tetanus or booster:
Eye
I do not want my teen to participate in the following:
Color
Phone #’s where I can be reached in an emergency:
this Fall
(Parent/Guardian Signature)
Rev. 2012
Grade
(Date)
Wears glasses?
Yes/No Wears
contact lenses?
Yes/No
Social Security
#
(SS# is not required by CEF East Texas. If the camper is sent to a clinic/hospital, the SS# will be required
before the patient is admitted.)
*Parent or guardian
*Address
*City
State
Zip Code
*Home Phone #
*Work Phone #
*Emergency Phone
#
*Health Insurance Company
Policy #
*Insured Parent’s Work Phone #
email- address
(CEF’s insurance pays only for accident expense not covered by your family insurance & does not cover illness, such
as colds, flu, appendicitis, etc.)
Family doctor
Phone
Address
City/State/Zip
MEDICAL HISTORY
Allergies to medications
Other allergies
Approximate date of last Tetanus Shot
/
/
Any known tendency to (check all that apply): ☐Earaches
☐Hay fever
☐Insomnia
☐Nervousness ☐Epileptic convulsions
Aches
☐Other
☐Headaches
☐Bedwetting
☐Asthma
☐Sleep-walking
☐Stomach
Any illnesses or accidents; date & status:
Does your child need any medications? Yes/No Name of medication(s)
How often/What time of the day?
In addition to prescribed medications, my child has my permission to receive the
following over- the-counter drugs: (circle the drugs you approve) Tylenol, Advil,
Cough Syrup, Stomach antacid, Decongestant, Antihistamine, Other
List heath or other conditions that would limit child’s participation in CEF®
activities:
MEDICAL CONSENT/LIABILITY RELEASE STATEMENT
I hereby release Child Evangelism Fellowship® Inc., Gospel Lakes Ranch, its staff,
board members, & agents from responsibility & liability for any injury or illness that
my child may sustain during the above-mentioned CEF® program. I hereby give
permission for my child to receive medical treatment in the event of an emergency. I
expect to be contacted as soon as possible.
Signature of Parent or Guardian
Date
☐Hyperactivity
☐Homesickness
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