Clone of Camp George 2025 Counselor Application

Camp George 2026 Volunteer / Counselor Application
Full Name*

First NameLast Name
Preferred Name
(Nickname/etc.)
YesNo
Tourette Syndrome / Tic DisorderADD/ADHDOCDNone - Family Member with TS/TDOther
Contact Number*
Format: (000) 000-0000.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
If yes, what years did you attend?
If no, how did you hear about camp?
T-Shirt Size*
Each counselor is provided 2 t-shirts to wear.
Can you please include a photo of yourself?

Headshots or selfies work!
Cancelof

Medical and Insurance Information
Preferred Name Insurance Carrier
Name on Insurance Card
Policy/Group No.
Insurance Card Front

Can upload PDF, PNG, JPEG
Cancelof
Insurance Card Back

Can upload PDF, PNG, JPEG
Cancelof
If you are unable to upload an image of your insurance card for any reason or have an insurance related inquiry, please email campgeorge@socaltaa.org.
Emergency Contact Information
First Contact Full Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Second Contact Full Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Dietary Restrictions and Preferences
VegetarianVeganGluten-FreeDairy-FreeNone
YesNo
Please describe.

Medical and Insurance Information