2019 Jr. Lifeguard Registration
Borough of Wildwood Crest
Junior Lifeguard Program
Address: Rambler Road & the Beach Wildwood Crest, NJ 08260
Phone: (609) 522-3825
Website: www.wcbp.org
First Name of Jr. Lifeguard *
Your answer
Last Name of Jr. Lifeguard *
Your answer
Grade *
Enter the grade your child is entering in the Fall.
Jr. Lifeguard's Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Best reached at
Your answer
Summer Address *
(Street, City, State, Zip Code)
Your answer
Adult T-Shirt Size *
Emergency Contact *
Your answer
Emergency Phone *
Your answer
Email Address *
Your answer
Medical Profile *
Will medication need to be dispensed?
Medical Profile
If yes, when?
Your answer
Child's Physician *
Your answer
Physician's Number *
Your answer
Health & Accident Coverage
Name of Company *
Your answer
Agreement # *
Your answer
Parent/Guardian Authorization
I hereby waive for myself and my child the right to assert any claim against the Borough of Wildwood Crest, the Wildwood Crest Lifeguards, and any of their agents, servants, or employees arising out of injury to the child due to participation in, preparation for, or travel to and from any recreation program or activity authorized by the Wildwood Crest Lifeguards. I relinquish any right that I or my child might otherwise have for payments of medical costs or other losses beyond whatever Insurance I have. I hereby authorize the director, staff, and volunteers of the Wildwood Crest Lifeguards to act for me according to their best judgement in any emergency requiring medical attention. I also authorize the Wildwood Crest Lifeguard Department to use pictures/images of my child for Program promotions. *
Parental Name
Your answer
By entering your initials in the box below, you are effectively providing your signature, indicating that you agree to the authorization and all the information on this form is true and accurate, to the best of your knowledge. *
Your answer
Registration fee: $50.00
Make checks payable to: Borough of Wildwood Crest
***PLEASE INCLUDE CHILD'S NAME IN CHECK MEMO
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