Lifeguard in Training 2022
Youth Section
Youth Name
First Name
Last Name
Preferred Name
Pronouns
Date of Birth
-
Month
-
Day
Year
Date
Age
Youth Cell Phone
Please enter a valid phone number.
Youth Email
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
T Shirt Size
School Attending
Grade 2022-2023
Custody Paperwork?
Yes
No
Parent/Guardian 1 Section
Parent/Guardian Name
First Name
Last Name
Pronouns
Email
example@example.com
Address (if different than youth)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Race
Please Select
Asian/ Pacific Islander
African American/Black
Alaskan Native
Hispanic
Native American
Caucasian/ White
Unspecified
Other
Does the youth live with you?
Yes
No
Employer
Work Hours
Parent/Guardian Date of Birth
-
Month
-
Day
Year
Date
Are you the custodial guardian of the youth?
Yes
No
Parent/Guardian 2 Section
Parent/Guardian Name
First Name
Last Name
Pronouns
Email
example@example.com
Address (if different than youth)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Race
Does the youth live with you?
Yes
No
Employer
Work Hours
Parent/Guardian Date of Birth
-
Month
-
Day
Year
Date
Are you the custodial guardian of the youth?
Yes
No
Medical/Developmental/Behavioral Information
Physical/Developmental/Behavioral Information to Share
List any allergies and recurring or chronic illness
Is the allergy...
Airborne
Contact
Ingested
List any current medications
Any dietary needs
Doctor Name
First Name
Last Name
Doctor Number
Please enter a valid phone number.
Dentist Name
First Name
Last Name
Dentist Number
Please enter a valid phone number.
Emergency Contacts and Authorized Pickups
Contact 1 Name
First Name
Last Name
Contact 1 Number
Please enter a valid phone number.
Relationship to Youth
Contact in case of emergency?
Yes
No
Authorized to pick up youth?
Yes
No
Contact 2 Name
First Name
Last Name
Contact 2 Number
Please enter a valid phone number.
Relationship to Youth
Contact in case of emergency?
Yes
No
Authorized to pick up youth?
Yes
No
Contact 3 Name
First Name
Last Name
Contact 3 Number
Please enter a valid phone number.
Relationship to Youth
Contact in case of emergency?
Yes
No
Authorized to pick up youth?
Yes
No
My youth can...
Check themselves out at the end of the day
Can only be checked out by guardian and those listed above
Sessions Attending
Please select all sessions youth will attend
Attending
Session 1 (July 5-14, $120 Members / $125 Non-Members)
Session 2 (July 18-28, $135 Members / $140 Non-Members)
Session 3 (August 1-11, $135 Members / $140 Non-Members)
LIT Questions
Please have the youth attending fill out the questions below
Why are you interested in the Lifeguard in Training program?
List 3 positive personality traits about yourself that you think make you a good candidate for LIT
List any hobbies or school activities you participate in
What do you want to do when you grow up?
Why are you interested in being a lifeguard/swim instructor?
How did you hear about the LIT program?
Family/Friend
Y Mailing
Y Website
Local Newspaper
Other
LIT Youth Agreements
Please have the youth participating fill out and sign below
Signature
Clear
Date
-
Month
-
Day
Year
Date
Parent/Guardian Agreements
Parent/Guardian must read and sign below.
Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: