BARNEGAT LIGHT BEACH PATROL
2019 Junior Lifeguard Application (For children ages 10-15)
An online form must be filled out for EACH child participating in the LIT program.

FEES: The fee for one session is $100.00.

PAYMENTS: Checks are made payable to "Borough of Barnegat Light". Please mail AFTER completing this form to:
P.O. Box 576, 10 East 7th Street, Barnegat Light, NJ 08006

DEADLINE for registration to guarantee clothing sizes: April 15. Registration will remain open until capacity is reached.

Name of Child *
Your answer
Summer Address & Phone Number *
Your answer
Permanent Address & Phone Number (if different than above)
Your answer
Email Address (a lot of communication via this medium! if multiple, separate by comma) *
Your answer
Sex *
Date of Birth *
MM
/
DD
/
YYYY
School attending & grade *
Your answer
!!!We are trying a new system. One 5 week session!!!
The program will run from June 24th to July 26th

Monday and Wednesdays will be the kids 13-15 years old

Tuesdays and Thursdays will be the kids 10-12 years old

Fridays will be everybody.

Please acknowledge that you have read the text above *
Clothing Sizes (all adult sizing)- Tshirt *
Clothing Sizes (all adult sizing)- shorts *
Clothing Sizes (all adult sizing)- sweatshirt *
Please take a moment and join our Facebook page: @BLBP LIT. We post a lot of very useful information on this page. Sometimes we post photos from tournaments/practice. If you do NOT want photos of your child on our FB group, please check below. If it is okay, please leave blank.
MEDICAL RELEASE INFORMATION: Injuries are inherent to sports; therefore in the event of an injury, I hereby release the Borough of Barnegat Light, its officers and volunteers, as well as all sponsors from all liability. I also understand that primary medical insurance is my responsibility if there is an injury. Since I am not present, I hereby give permission for any and all medical attention necessary to my child in the event of an accident, injury, sickness, etc. under the direction of the person(s) checked by me below until such time as I may be contacted. *
Required
HOLD HARMLESS/INDEMNIFICATION AGREEMENT: I, the parent of the above named child, give my approval for him/her to participate in any and all activities of the Junior Lifeguard Program. I hereby fully indemnify and hold harmless the Borough of Barnegat Light, its officers, agents, its employees and volunteers from any and all claims from injuries, including death, damages or loss, which may arise or which may be alleged to have arisen out of, or in connection with this program. (CHECK YES BELOW IF AGREE) *
Required
In the space below, please provide the following: 1- Insurance Company; 2- Policy Number; 3- Physician, Telephone Number & Address; 4- Known Allergies and/or Medical Conditions *
Your answer
Please explain anything else necessary for instructors to know (cpr certified, lifesaving certified, etc.)
Your answer
IN CASE OF EMERGENCY (name, relation & phone number) *
Your answer
ELECTRONIC SIGNATURE & date *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service