Counselor Application

Please fill all required fields (marked with *)

First Name* Last Name* Counselor Email* Counselor Cell Phone* Father Name (First & Last)* Mother Name (First & Last)* Parent Email* Parent Cell Phone (Primary)* Parent or Emergency Cell Phone Number* Date of Birth* Home Address* City* State* Zip Code* School Now Attending* Entering Grade* GPA* Please indicate any health factors (including dietary restrictions) that staff members should be aware of. Read the waiver and release Please sign your name (Parent/Guardian)*