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Відпічнім з Христом - Break for Jesus
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Period
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Break for Jesus - 2025
Name
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Date of Birth
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Grade
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Parish
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Phone
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Email
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Registration #:
Address
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Additional
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Declaration
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Address Line 1
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Address Line 2:
City
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Postal Code
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Country
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Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
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Dominica
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Grenada
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Guinea
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Haiti
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Holy See
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India
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Iraq
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Israel
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Japan
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Jordan
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Malawi
Malaysia
Maldives
Mali
Malta
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Martinique
Mauritania
Mauritius
Mayotte
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Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
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Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
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Sao Tome and Principe
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Senegal
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United States Minor Outlying Islands
United States of America
Uruguay
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Vanuatu
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Wallis and Futuna
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Zambia
Zimbabwe
Province
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Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Emergency Contact 1
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Emergency Contact 2:
Why do I want to be a counselor?
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Leadership experience:
What can I offer to make the children's experience at camp memorable?:
Level of Ukrainian
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Medium
Minimal
None
Strong
Reference 1
Name
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Position/Title
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Phone
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Email
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Reference 2
Name
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Position/Title
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Phone
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Email
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I have no convictions, charges or pending charges for offences under the Criminal Code of Canada up to and including the date of this declaration for which a pardon has not been granted under the Criminal Records Act of Canada.
Signed At
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Last police Check
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Signature of Child
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Signing Date
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Parents Name
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Parents Email
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Signature of Parent / Guardian
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Signing Date
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