BAC Lifeguard Course Sign-up Form

1

How did you hear about our lifeguarding course?* This field is required.Select all that applies.

BAC website

BAC email

BAC Facebook

BAC Instagram

Friend

Other

2

Name of referral friendPlease complete this section if someone referred you to this class. Your referral will receive $10 off the course if they attend your same course on the same day.

First Name

Last Name

3

Student's Name* This field is required.

First Name

Last Name

4

Student's Email* This field is required.This will be the email linked to your American Red Cross account.

example@example.com

5

Phone Number* This field is required.

Please enter a valid phone number.

6

Date of Birth* This field is required.Please note: If taking the full lifeguarding course, you must be 15 years old by the last day of the course and 17 years old by the last day of the recert course. You are required to bring a photo ID with your birthdate on the first day of the course for proof of age for the full cert and recert courses. You can bring a student ID and a birth certificate if you do not have a passport or driver's license.

Date

7

Parent/Guardian’s NameSkip if 18 years old or older.

First Name

Last Name

8

Parent/Guardian’s Phone NumberSkip if 18 years old or older.

Please enter a valid phone number.

9

Do you have an expiring lifeguarding certification?* This field is required.

YESNO

10

Please upload your expiring Lifeguard CertIf your cert expired over 30 days by the last day of the course, you will have to redo the full lifeguarding course.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

11

Lifeguard Course Date

Oct 26th and 27th 10 am to 9 pm

12

Lifeguard Recert Course Date

Oct 26th 10 am to 9 pm

13

Waiver* This field is required.In consideration of my use of the pool and facilities provided by Berkeley Aquatic Club (BAC) and Fairleigh Dickinson University (FDU)., I expressly agree and contract, on behalf of myself, my heirs, executors, administrators, successors and assigns, that arising from personal injuries (including death) sustained by me, in, on, or about the premises, or as a result of the use of the pool or facilities, regardless of whether such injuries result, in whole or in part, from negligence of BAC or FDU. By the execution of this agreement, I accept and assume full responsibility for any and all injuries, damages (both economic and non-economic), and losses of any type, which may occur to me or my child/ward, and I hereby fully and forever release and discharge BAC and FDU, its insurers, employees, officers, directors, and associates, from any and all claims, demands, damages, rights of action, or causes of action, present or future, whether the same be known or unknown, anticipated or unanticipated, resulting from or arising out of the use of said pool and facilities. I expressly agree to indemnify and hold BAC and FDU harmless against any and all claims, demands, damages, rights of action, or causes of action, of any person or entity, that may arise from injuries or damages sustained by me or my child/ward. I agree to be solely responsible for the safety and well-being of myself. I agree to comply with all rules imposed by BAC and FDU regarding the use of facilities and equipment. I agree to conduct myself in a controlled and reasonable manner at all time, and to refrain from using equipment in a manner inconsistent with its intended design and purposes. I understand and acknowledge that the use of the pool and equipment involves risk of serious injury, including permanent disability and death. I hereby certify that I know of no medical problems that would increase my/my child’s/my ward’s risk of illness or injury as a result of use of the facilities and/or equipment. I understand and agree that BAC and FDU are not responsible for property that is lost, stolen or damaged while in, on, or about the premises. I have read the foregoing waiver and release of liability and have voluntarily executed this document with full knowledge of its content.

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