2004 Lifeguard Registration Form

Mail it to: S.A.F.E.
5 Otsego Ave
Lowell, MA 01851
Print out this Form,
Complete and mail with your check
Make payable to "S.A.F.E."
This form is provided by S.A.F.E.

 

Name: ________________________________________________________

Parent's Name: _________________ Emergency Phone: ________________

Address: ______________________________________________________

Town: ___________________ State: ________ Zip: __________

Phone Number: _________________________________________________

E-Mail Address: ________________________________________________

Age: ______________ # of Years Lifeguarding: ___________

Place of Employment for Summer of 2003: ___________________________

Place of Employment for Summer of 2004: ___________________________

Recertification or New?: ___________________________________________

Indicate desired program by placing a value in the Qty column and calculating the Extended Price.
Cost
Session
Qty
Extended Price
Lifeguard
$200.00
May 14 - 16
__
$ ___ . ___
May 17 - 20
__
 $ ___ . ___
May 28 - 30
__
$ ___ . ___
June 4 - 6
__
 $ ___ . ___
Total
$ ___ . ___

I agree to hold harmless S.A.F.E., Jason Malinowski, Harvard Ridge Pool Club, and/or its employees from claims or liability related to any accident that may occur. I give my permission for medical treatment to be given if the need arises.

____________________________________________ Date: ________________
Signature (Parent/Guardian if under 18)

I have read and understand the S.A.F.E Refund Policy, my check for the Total amount is enclosed.

Signature __________________________________________ Date: _______________

Copyright © S.A.F.E.. All rights reserved. Last updated: Apr. 7, 2004