Counselor Information Form

Part One: General Information

* Indicates required field

1. Name *

2. WeChat ID: *

3. Phone Number *

4. Which program are you part of this Summer? *

5. Do you have availability in August or any possible auxiliary programs? *

If "Other," please specify *

If "Depends on when," please specify: *

6. Do you have any dietary restrictions? *

7. Allergies? *

8. Any medical conditions you would like the program director to be aware of? *

9. Among the students, do you have an age group you'd feel most comfortable working with? *

Part Two: Emergency Contact Information

In the unlikely event of an emergency during the program, please provide the information for at least one emergency contact. Your emergency contact does not need to be a family member, but they should be:

Someone you trust
Actively responsive to phone and email
Aware of any medical concerns you may have

10. Emergency Contact Name *

12. Emergency Contact Email *

11. Emergency Contact Phone *

13. Emergency Contact Relationship to You *

If you would like to add a second emergency contact, you may use questions 14-17 to do so:

14. Emergency Contact Name *

16. Emergency Contact Email *

15. Emergency Contact Phone *

17. Emergency Contact Relationship to You *

Part Three: Bank Information

18. Bank Name *

19. Routing Number *

20. Account Number *

21. Type of Account *

If "Other," please specify *

22. Home Address Associated With This Account *

Line 1

Line 2

City

State

Zip Code

Country

Part Four: Photo Waiver

Check the box: *

I hereby grant permission to Boston Roundtable to use photographs and/or video of me taken during the duration of my program session in publications, news releases, online, and in other communications related to the educational mission of Boston Roundtable.

Any additional comments? *

Submit

Boston Roundtable 2019 Counselor Information

Part One: General Information

Part Two: Emergency Contact Information

Part Three: Bank Information

Part Four: Photo Waiver

Boston Roundtable
2019 Counselor Information