Counselor Application – Connecticut Burns Care Foundation

Camp Dates: July 21-28, 2024

New Counselor Application

0% Complete

1 of 11

First Name *

Middle Name *

Last Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Country *

Home Phone Number *

Cell Phone Number *

US Citizen? *

Yes

Date of Birth *

Email Address *

Please fill in your full mailing address:

List Any Other Names, Nicknames, or Aliases You Have Been Known By:

List All of Your Residences For The Past Ten (10) Years with Dates To/From: *

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Emergency Contact Phone #2

Emergency Contact Phone #3

Secondary Emergency Contact Name

Secondary Emergency Contact Relationship

Secondary Emergency Contact Phone Number

Secondary Emergency Contact Phone #2

Secondary Emergency Contact Phone #3

Current Employer - Please include Company Name, Street, City, State & Zip: *

Please upload a current photo of yourself: *

Maximum file size: 267.39MB

If you are human, leave this field blank.