Atlantic Beach Ocean Rescue 2011 Summer Season

Returning Lifeguard Application

Name:

Last

First

Middle

Summer Address & Phone:

Street

City/State

Zip

Phone

Cell phone

E-mail address

Current Address & Phone:

Street

City/State

Zip

Phone

Social Security Number

Driver License No.
(attach a copy)

State

Bathing Suit Waist Size:

T-Shirt Size:

Small Large

X-Large XX-Large

List previous summer seasons employed by the Atlantic Beach Patrol

Check desired employment:

Full-time

Part-time

Please list dates for the following:

The earliest weekend day available for testing (500 meter swim in 10 min. or less):

The earliest weekend day available for Pre-season Returning Guard Training:

The earliest weekend day available for weekend Beach Patrol operations:

The earliest day available for full time:

The last day available for full time Beach Patrol operations:

The last day available for Weekend Beach Patrol operations:

Please list your employment, and/or education since last summer, include any applicable training, seminars, and/or certifications you may have received since last season (for the next newsletter)

Have you received the Hepatitis B vaccination series?

Yes

No

If no, do you wish to receive the Series?

Yes

No

In case of emergency, who do you wish us to contact?

Name

Relationship

Phone

Address (Street)

City/State

Zip Code

Please attach copies of all current EMS Certifications, current driver's license and social security card. Also, complete and attach a W-4 Form and an I-9 Form. Your application will not be accepted otherwise.

I hereby attest that the information I am submitting is truthful and accurate to the best of my knowledge.

Signature of Applicant

Date