CYIA Pre-Training Release Form

May 10th, 2025 8:30am - 6:00pm | Pre-Training at Melrose Community Church
3918 Melrose Rd.
Roseburg, OR 97471

Please fill out this form and click submit.
Student Information

 
 
 
 
 
 
 
Emergency Contact Information

 
 
Transportation & Food

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Medical Information

 
Liability Release

"I hearby give permission for the above named minor to attend and participate in the Christian Youth In Action pre-training. I release and hold harmless Child Evangelism Fellowship Inc., its staff and volunteers, and the facilities used from responsibility and liability for any illness or injury that my child may sustain during this activity, provided they have exercised reasonable caution and supervision toward the safety of my child. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to any X-ray examination, medical, dental, or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office, or in any hospital. I expect that this adult leader will notify me personally, as soon as possible if there is an accident requiring the services of a physician."
 
 

Description

May 10th, 2025 8:30am - 6:00pm
Pre-Training at Melrose Community Church
3918 Melrose Rd.
Roseburg, OR 97471

Please fill out this form and click submit.