CIT Application

Welcome to the WJCC Camp Sameach CIT Program. Please fill in all required information.

Teen Information (Required):

First Name : 
Last Name : 
Gender : 
Home Address : 
City : 
State : 
Zip : 
Home Phone : 
Teen Cell Phone : 
Teen E-mail : 
Birthdate : 
Grade in Fall of 2012 : 
School : 
T-Shirt Size : 

Parent 1 Information (Required):

Parent 1 Name : 
Parent 1 Cell Phone : 
Parent 1 E-mail : 

Parent 2 Information (Optional):

Parent 2 Name : 
Parent 2 Cell Phone : 
Parent 2 E-mail : 

Emergency Contact and Medical Information (Required):

Emergency Contact : 
Emergency Contact Phone Number : 
Emergency Contact Relation : 
Doctor's Name : 
Doctor's Phone Number : 
Insurance Company : 
Insurance Plan Number : 
Special Needs/Allergies/Medical Issues : 

CIT Program Information (Required):
To be filled out by teen.

Which days are you interested in working?
Which session are you interested in working?
Have you ever been a CIT before?
If yes, where?
Why are you interested in this program?