Clone of Junior Lifeguard Registration

JG Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

What is your child's T-shirt Size? (Adult Sizes)

Does the JG have any allergies, chronic illnesses, or medical conditions? If yes, please describe.

Is the JG prescribed an inhaler? If yes, please explain any instructions.

ACCIDENT WAIVER AND RELEASE OF LIABILITY

NOTICE TO THE MINOR CHILD’S PARENT/GUARDIAN:
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF CURRY COUNTY USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A RISK OF INJURY AND/OR DEATH BY PARTICIPATING IN THIS ACTIVITY DUE TO CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM, YOU ARE RELINQUISHING YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM
CURRY COUNTY IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD; OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND CURRY COUNTY AQUATIC SAFETY HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

I, {name} for myself, my heirs and personal
representatives, hereby assume all liabilities, risks, injuries and hazards to my child,
{jgName}, incidental to, or as a result of,
participation in the 2026 JUNIOR LIFEGUARD PROGRAM (also referred to herein as the “Program,” including transportation to, from, and during the program. I freely acknowledge the fact that this Program may have, and/or do involve, physical contact or other conditions or factual circumstances where physical or other injuries may occur, and that transportation to and from said event could involve the potential for an automobile, or other, accident. As legal guardian and/or natural parent of the above-referenced child, I do hereby warrant that my minor child is in good health and has no physical condition that would prevent him/her from safely participating in the program identified above. If my minor child has any medical or physical limitation, I have made Curry County Aquatic Safety staff aware of such limitations in writing in advance of my minor child’s participation in the program, which does include swimming and water activities.

As legal guardian and/or natural parent of the above-referenced child, I do hereby waive, release, and agree to indemnify and hold harmless Curry County, their officers, agents, employees, the organizers, sponsors, activity supervisors, co-sponsoring organizations, and participants for any claim, demand, liability, costs, suits, charges, or compensation for loss or injury of any kind arising out of a loss or an injury, including losses or injuries arising from the negligence of Curry County, their agents or employees, and sponsors or activity supervisors, arising from my child's participation in the said activity. I, as legal guardian and/or natural parent of the above-referenced child, assume all risk of injury, liability, and loss arising from my child/children’s participation or presence at said activity. I acknowledge that Curry County will not assume any costs relating to any injury while my
child/children are involved in this activity, or from transportation to or from this activity.

This Waiver, Release, and Hold Harmless/Indemnification Agreement is in consideration of Curry County permitting my child’s participation in the Program, and further in consideration of Curry County not requiring self-funded liability insurance coverage on my part as a condition precedent to my child’s participation in the activity.

I, as legal guardian and/or natural parent of the aforesaid child, freely and voluntarily assume all risk of loss or injury arising from my child’s participation in the activity, whether due to my negligence, my child's negligence, or the negligence or intentional acts of others. I acknowledge that, absent this release and indemnification, Curry County, or other sponsors of the activity, would not have offered me, or my child/children, the access to the activity because of unacceptable exposure to civil liability claims and/or lawsuits, or the expense of providing a program that is risk-free. By signing this waiver, I agree to
indemnify any and all employees of the Curry County for any and all damages that result from any and all acts or omissions, including negligence, in whole or in part, on the part of any county employee. I have read and understood this document and sign it freely and knowingly, intending that it shall be fully operative and effective in all respects and that it waives legal rights to which I, or my child/children, might otherwise be entitled if my child/children are hurt or suffer loss during his/her/their participation in that activity.

YOU MUST CAREFULLY READ THIS DOCUMENT BEFORE SIGNING IT. YOU ARE WAIVING OR RELEASING VALUABLE LEGAL RIGHTS. YOU ARE ADVISED TO SEEK THE ADVICE OF AN ATTORNEY IF YOU DO NOT FULLY UNDERSTAND THIS DOCUMENT.

Medical Release and Authorization (Choose One)

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which, in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering, or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination, and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to Curry County and its affiliates, including directors, Aquatic Safety personnel, and parents who are participating, to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of the life and limb of the named minor child, in my absence.As Parent and/or Guardian of the named athlete, I hereby DO NOT authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which, in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering, or discomfort, if delayed. Permission is hereby NOT granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination, and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. Permission is also NOT granted to Curry County and its affiliates, including directors, Aquatic Safety personnel, and parents who are participating, to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of NOT authorizing medical treatment under emergency circumstances, for the protection of the life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Date

Signature

Junior Lifeguard Sessions

Sunset Bay Beach—Coos Bay, OR; June 22nd – 26th, 2026

5 Day Session

$200.00 Quantity

Port Beach—Port Orford, OR; July 27th - 31st, 2026

5 Day Session

$200.00 Quantity

Harris Beach—Brookings, OR; August 10th - 14th, 2026

5 Day Session

$200.00 Quantity

JG Aid Division

Must be at least 14 years of age and have completed at least one prior JG Session.

$200.00

	Quantity
Sunset Bay Beach - Coos Bay, OR; June 22nd - 26th, 2026
Port Beach - Port Orford, OR; July 27th - 31st, 2026
Harris Beach - Brookings, OR; August 10th - 14th, 2026

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Total

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

2026 JUNIOR LIFEGUARD REGISTRATION

Junior Lifeguard Information

Junior Lifeguard Sessions

Payment Methods