Counselor's Name *

First Name

Last Name

Parent/Guardian's Name *

First Name

Last Name

Parents' Phone *

(###)

###

####

Counselor's Phone (if applicable)

(###)

###

####

Select your available sessions

Week 1: June 23 - 27

Week 2: June 30 - July 3 (short week for July 4)

Week 3: July 7 - 11

Week 4: July 14 - 18

Week 5: July 21 - 25

Week 6: July 28 - Aug 1

Week 7: Aug 4 - 8

Week 8: Aug 11 - 15

Week 9: Aug 18-22