J-1 Camp Lifetraveled Counselor Program Registration Form (New Members)
Instructions: Before you start this application, ensure to the have the required documents listed on the J-1 USA Camp Counselor Program website or congratulations email.
Personal Details
Name
*
First Name
Last Name
Gender
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a Drivers License?
*
Yes
No
Program Eligibility
Type a question
*
Post Secondary Student (College/University)
Teacher
Youth Worker
Special Skill
College/University/Employer:
*
College/University/Employer's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
College/University/Employer's Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Year of Study: (Students must enter):
-
Month
-
Day
Year
Date
Graduation Date (Students must enter):
-
Month
-
Day
Year
Date
Major (Students must enter):
Program Start Date
*
-
Month
-
Day
Year
Date
Program End Date
*
-
Month
-
Day
Year
Date
Emergency Contact
Name
*
First Name
Last Name
Relationship
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Health History
Do you have an illness that may impair your ability to work?
*
Are you taking any medications?
*
Yes
No
If yes, state:
Are you Covid-19 vaccinated?
*
Yes
No
If yes, state the manufacturer:
Travel History
Do you have travel History within the past 5 years?
*
Yes
No
Do you have a US Visa?
*
Yes
No
Visa Control Number
Visa issue date:
-
Month
-
Day
Year
Date
Visa expiry date:
-
Month
-
Day
Year
Date
Have you ever been denied a visa?
*
Yes
No
If yes, please state why?
Have you ever been denied entry, or your visa revoked?
*
Yes
No
Have you ever been arrested or have anycases before the court?
*
Yes
No
J-1 Program History
Have you participated in any Bridge USA Program?
*
Yes
No
Which program?
*
For example: Summer Work and Travel
Document Upload
Program Deposit Fee Receipt
*
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Passport Bio Page
*
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Smiling Professional Photo
*
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CV/Resume
*
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Eligibility Document: Proof of your status as a student (STATUS LETTER), youth worker or teacher (Job Letter), Special Skill (Certificate)
*
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Signed Agency J-1 Camp Counselor Program Terms and Conditions
*
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Signature
*
Submit
Should be Empty: