2021 Summer Program Counselor Application
DEADLINE is April 1.
First Name *
Middle Name *
Last Name *
Permenant Street Address/PO Box *
City *
State *
County *
Zip code *
Telephone Number *
Email address *
Social Security Number
If desired, applicants may submit their social security numbers following selection for the program. Failure to include your social security number on this application may delay receipt of stipend provided to program participants.
Gender (Select One) *
Name of College *
Major *
Minor, if applicable
(Expected)Graduation Date *
Race/Ethnicity (Mark All That Apply) *
T-shirt size (Select One) *
Options are adult sizes
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