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J-1 Camp Counsellor Application Form

    Last Name (required):
    First Name (required):
    Middle Name (required):
    E-mail (required):
    Address:
    Contact #:
    D.O.B.
    Skype ID (required):
    Number of Dependent (s):
    Nationality:
    Age:
    Gender:
    Upload Your Resume/CV
    Upload Your School ID
    Upload Your Passport Information Page
    Upload Your Passport Size Picture
    Upload Your Certified Status Letter
    Passport #:
    Passport Expiration Date:
    Passport Issue Date:
    Social Security #:
    Name of Institution:
    Address of Institution:
    Field of Study:
    Year of Study:
    Expected Date of Completion:
    Name and address of high school attended:
    Year started:
    Year ended:
    What option are you applying for?
    Give two job preferences in the space below:
    Have you ever participated in this program before?
    If yes, state where:
    Sponsor:
    Position held:
    Year participated:
    Would you like to work at the same location as a friend?
    If yes, please give your friend’s name:
    Do you have any family and/or friends in the USA?
    If yes, please state their names, relationship and address:
    Status of immediate family in the USA:
    Have you ever been denied a US visa?
    Have you ever lost a passport?
    Have you ever been convicted of a crime?
    If yes, explain:
    Do you have any serious illnesses and/or allergies?
    If yes, specify:
    Marital Status
    Spouse's Full Name:
    Spouse's D.O.B.
    Who will pay for your trip?
    Address of person paying for your trip:
    Next of Kin/Emergency Contact Name:
    Next of Kin/Emergency Contact Address:
    Next of Kin/Emergency Contact #:
    Next of Kin/Emergency Contact Email Address:
    Next of Kin/Emergency Contact Relation:
    Father's Name (required):
    Father's D.O.B.
    Mother's Name (required):
    Mother's D.O.B.
    Give three references
    First Reference Name:
    First Reference Occupation:
    First Reference Address:
    First Reference Contact #:
    First Reference Relation:
    Second Reference Name:
    Second Reference Occupation:
    Second Reference Address:
    Second Reference Contact #:
    Second Reference Relation:
    Third Reference Name:
    Third Reference Occupation:
    Third Reference Address:
    Third Reference Contact #:
    Third Reference Relation:
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    Are you on social media? If yes, list social media accounts usernames so that we can connect with you: