NJ Lifeguard | Waterfront Lifeguard Registration | WML

Class Location: White Meadow Lake Drum Pool
Class Category: New Student - Waterfront Lifeguard Add-On Module

Address:
White Meadow Lake Drum Pool
5-11 Iowa Ave
Rockaway, NJ

Waterfront Course Date*

Student Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email*

Confirmation Emailexample@example.com

Phone Number*

Please enter a valid phone number.

Student Birthdate*

Date

If student is under 18, please enter name of parent/guardian:

Emergency Contact Name*

Emergency Contact Phone Number*

Does the student have any medical history/problems? (Asthma, Diabetes, Seizures, Other, Etc).

Does the student have any allergies? If yes, please share details.

Release of Liability, Medical Treatment Authorization, and Consent*

(Click here: I've read and agree) As the student, legal parent or guardian, I release and hold harmless NJLifeguard, LLC, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of NJLifeguard, LLC, its owners and operators or in route to or from any of said premises. In consideration of and through my involvement in the Lifeguard Training Programs offered by NJLIFEGUARD, LLC at our scheduled training locations or any off-site location services are offered, I (or on behalf of my minor child), acknowledge and agree that I risk bodily injury, including paralysis, dismemberment, and death, as well as loss or damage to property; I knowingly and freely assume all such risk; and I (or on behalf of my minor child) for myself, and on behalf of my heirs, assigns and next of kin hereby release, hold harmless and promise not to sue NJLifeguard LLC, Drew University, Rider University, Windsor Athletic Club or any off-site training location, the instructors of the program, or the persons involved in the facilitation of this program, with respect to all such injury, paralysis, dismemberment, death and/or loss or damage (except that which is resultant of gross negligence and/or willful or wanton misconduct.) I certify that (or on behalf of my minor child) to be the best of my knowledge, I am in good physical condition and have no disease or injury that would impair my performance or result in my being injured during any program participation. In addition, I (or on behalf of my minor child) do hereby grant permission for duly authorize medical treatment by certified professionals to be administered to me (or my minor child) in the event of injury and that all costs are my responsibility. The above customer also agrees to allow NJLIFEGUARD, LLC to use images or videos taken in any format, for use at any time, in any media, marketing, illustration, and promotional materials. A customer/parent/guardian can change their mind at any moment by informing us.

Covid Statement*

(Click here: I've read and agree) Despite our careful attention to disinfection of equipment (CPR mannequins, other) and use of personal barriers, there is still a chance that you could be exposed to an illness in our training program, just as you might at the gym, grocery store, or restaurant. "Social Distancing" nationwide has reduced the transmission of the Coronavirus. Although we take measures to provide a safe environment, due to the nature of the services we provide, it is not completely possible to maintain social distancing between students making rescues on land or in the water. However, the American Red Cross has provided guidance to instructors on how to reduce contact and social distance to maintain a safe learning and training environment. Having said that, while mitigation efforts will take place, contact cannot be completely avoided. Although the exposure is unlikely, you are consenting to the risk.

Please type in your full name acknowleding the Release of Liability, Medical Treatment Authorization and Consent*

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