| Name: |
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| Address: |
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| City:
State:
Zip:
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| Home Phone:
Work:
Cell:
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| E-Mail Address: |
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| Date of Birth:
T-Shirt Size:
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Are there any changes over the last year which would preclude you from participating in activities this year?
Yes
No
If yes, please explain:
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Have you ever been convicted of a crime involving any type of sexual offense?
Yes
No
If yes, please explain:
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Have you ever been convicted of a crime pertaining to the use of alcohol?
Yes
No
If yes, please explain:
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Have you ever been convicted of a crime pertaining to the use of any controlled substance, including but not limited to, drugs?
Yes
No
If yes, please explain:
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| Please list any allergies:
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| Do you want to share your name, address, phone & e-mail address with other counselors?
Yes
No |
NOTE: At no time do you ask or take a child's name and address. If a child wants your name to write to you, give them the Foundation's address so that we can date when they first contacted you. This is due to the Right of Privacy Law. The address of the Foundation is:
Connecticut Burns Care Foundation, Inc., 601 Boston Post Road, Suite 2, Milford, CT 06460
IN CASE OF AN EMERGENCY, PLEASE CONTACT: |
| Name:
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| Relationship:
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| Home Phone:
Work:
Cell:
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IMPORTANT:
I attest the information provided is accurate and truthful to the best of my knowledge:
Yes
No
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