Register for Counselor

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Period *:

Name *:

Date of Birth *:

Grade *:

Parish *:

Phone *:

Email *:

Address Line 1 *:

Address Line 2:

City *:

Postal Code *:

Country *:

Province *:

Emergency Contact 1 *:

Emergency Contact 2:

Why do I want to be a counselor? *:

Leadership experience:

What can I offer to make the children's experience at camp memorable?:

Level of Ukrainian *:

Reference 1

Name *:

Position/Title *:

Phone *:

Email *:

Reference 2

Name *:

Position/Title *:

Phone *:

Email *:

I have no convictions, charges or pending charges for offences under the Criminal Code of Canada up to and including the date of this declaration for which a pardon has not been granted under the Criminal Records Act of Canada.

Signed At *:

Last police Check *:

Signature of Child *:

Signing Date *:

Parents Name *:

Parents Email *:

Signature of Parent / Guardian *:

Signing Date *: