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Junior Lifeguard Program Registration 2013 - Town of Shellbrook


									                                                  Junior Lifeguard Program                      PLEASE PRINT AND COMPLETE
                                                      Registration 2013
Participant Information:                                                                                   Page - 1
Participant Name:                                                                 Participant D.O.B:       /      /

Participant Address:                                                              Postal Code:

Parent/Guardian Information:

Parent/Guardian Name(s):                                      Relationship to participant:

Telphone (Home):                                              Telephone (Cell):

Email Address:

Junior Lifeguard Program Registration Fees         $75.00
Includes Junior Lifeguard T-Shirt.

Please tick which size Junior Lifeguard T-Shirt you would like:

Childrens Small                                   Adult Small

Childrens Medium                                  Adult Medium

Childrens Large                                   Adult Large

Childrens X-Large

   We accept cash and cheques at the Swimming Pool. Cheques are to be made out to the Town of Shellbrook.
              You can also pay for fees at the Town Office where cash, cheques and debit is accepted.
Official Use Only:
Payment Due : $75.00                  Method of Payment:     Cash Chq & #            Receipt#

Medical Information:
Please indicate below if the participant has any medical issues or medication requirements that the we should be aware of?
(i.e. diabetes, epilepsy, allergies….etc.)
Please List:
Emergency Contact Name (If different from Parent/Guardian):                       Contact No:
Health Card Number:

                                                  Please Turn Page
                                                 Junior Lifeguard Program                   PLEASE PRINT AND COMPLETE
                                                    Registration 2013
                                                                                                         Page - 2
Release and Waiver of Claim:
Please read, complete and sign.

 (Please Print) I,                                  , parent/legal guardian of child,
hereby acknowlege and agree that in consideration of his/her being permitted to participate in the Junior Lifeguard
Program offered by the Town of Shellbrook:
       i. I understand and acknowledge the risks inherent with the activites carried out during the program, and hereby
          accept and assume all such risks which I or the participating youth for whom I act as guardian may be exposed.
     ii. I am sufficiantly informed to represent to the Town that the participant does not suffer any condition that may
          affect his/her ability to safely participate in the program. I also acknowlege that the town reserves the right to
          required medical certificate in respect to my or his/her ability to participate.
     iii. I have carefully read and understand clearly that by signing this Release and Waiver of Claim, I will be forever
          prevented from suing against the Town of Shellbrook or any employee, agent, Parks Board member or officer
          thereof for any propery loss, or personal injury that I or the youth may suffer while participating in the program.
    iv. I also acknowledge that the Town of Shellbrook would not permit me or him/her to participate unless I signed
          the Release and Waiver of Claim and agreed to comply with the rules and regulations as set out by the
          Town of Shellbrook.

  Date:                     Signature:                                  Witness:

Photograph Release Declaration:
Please read, complete and sign.

  (Please Print) I,                             , parent/guardian of participant,
grant Shellbrook Swimming Pool the right to take photographs of named participant. I authorize Shellbrook Swimming
Pool to copyright, use and publish in print and/or electronically.

I agree that Shellbrook Swimming Pool may use such photographs of the named participant with or without identificatio
for any lawful purpose, including for example publicity, illustration, advertising and Web content.

I have read and understand the above statements:


Printed Name:

            Junior Lifeguard Program   PLEASE PRINT AND COMPLETE
               Registration 2013

aware of?
              Junior Lifeguard Program   PLEASE PRINT AND COMPLETE
                 Registration 2013


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