Youth Counselor Application
Applicant Name
*
First Name
Last Name
Applicant Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Applicant Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Email
*
example@example.com
Applicant Age (How old you'll be on the first day of camp.)
*
Applicant Grace (What grade you'll be in for the upcoming school year)
*
Will you be available for every day of Camp? (August 4-8)
*
Yes
No
Age Group you prefer to work with (This does not mean you will automatically be assigned this age group, but we will try to honor preferences.)
T Shirt Size
*
Please Select
Child Large
Adult Small
Adult Medium
Adult Large
Adult X Large
Adult XX Large
Parent or Guardian Name
*
First Name
Last Name
Parent or Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent or Guardian Email
*
example@example.com
Reference Name and Phone or Email
*
Please provide a non-family member adult such as a teacher that would recommend you as a youth counselor.
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Info: Please list any physical restrictions, special dietary needs or other special needs. List medications currently being given, if any.
Primary Care Physician
*
Are you up to date on required school immunizations as far as you know?
*
Yes
No
Have you ever been accused of child abuse or neglect?
*
Yes
No
Submit
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