Counselor Application – Connecticut Burns Care Foundation

Camp Dates: August 20-27, 2023

New Counselor Application

First Name *

Middle Name *

Last Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Country *

Home Phone Number *

Cell Phone Number *

Email Address *

Date of Birth *

US Citizen? *

Yes

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: *

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

Please upload a current photo of yourself: *

Maximum upload size: 267.39MB