LFYC Counselor Registration | Lighthouse Ministries

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Company

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Counselors, please fill out this form. If you have any questions, feel free to contact Lighthouse at 855-776-3123. Thank You!

Church Organization*

Church Phone Number*

Pastor's Name*

Counselor's Name*

Phone Number*

Age*

Gender*

Emergency Contact*

Relationship to Counselor*

Emergency Contact Phone Number*

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Staying on Campus

Staying in a Hotel

Counselor's Signature*