Shift Counselor Registration Form

Counselor Registration Forms must be submitted by August 28th, 2022, to:

Theo Cox, 3290 N Mount Juliet Rd, Mount Juliet TN 37122
Name
Email
example@example.com
Parent/Guardian Name (If under 18)

First NameLast Name
Parent/Guardian Email
example@example.com
Address
City
State
Zip
Cellphone #
Work #
Date of Birth

MonthDayYear
Date
T-Shirt Size
Favorite Candy
Counselor Type:

AdultJunior Counselor
Emergency Contact
Relationship
Contact Number:
Please enter a valid phone number.
Email
example@example.com
Please note anything you feel we need to know about you. Thank You!
By Signing below, you agree to get a district background check if needed and are at least 15 years of age or older. You also agree to follow any Nazarene Safe protocol to ensure that campers and staff are protected. Parent Signature is required for Junior Counselors.
Counselor Signature

Clear
Junior Counselor's Parent Printed Name
Junior Counselor’s Parent Signature

Clear
Should be Empty: