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Counsellor in Training Application Form

Please fill in the form below and submit. Fields with a ( * ) beside them are required.

* First & Last Name:
* Address:
* City:
* Province/State:
* Country:
* Postal Code:
* Phone Number:
Email:
* Birth Date:
* Period Available:
High School Attending :
* Do you know anyone employed by this agency?	Yes No
if yes, who?
* Hobbies and Interests:
* Why do you want to participate in this program?
* Have you ever worked with people with physical or intellectual disabilities before?	Yes No
When?
Miscellaneous Comments, if any
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