Okaloosa County Beach Safety
JUNIOR LIFEGUARD PROGRAM Summer 2017
Name of Participant:
Shirts Adult Size: S, M, L, XL Girl Shorts: S, M, L
Boy Shorts: 24, 26, 28, 30, 32, 34 ,36
Address:
Sex:
Age:
Date of Birth:
Parent Name(s) or Guardian
Phone:
Work Phone:
Email: ________________________
Physician’s Name:
Phone:
Person to contact in case of emergency, other than listed above:
Name:
Phone:
Address:
Any medications taken?
When is it taken?
Are there any side effects?
If yes, please explain:
Are there any special care instructions:
If yes, please explain:
Are there any type of activities your child can not take part in due to medical or other reasons?
If yes, please explain:
please add any other information that would be helpful to us:
The undersigned parent or legal guardian of participant in the sports and recreational activities provided by
Okaloosa County understands that participation in any sport or recreational activity subjects the participant
to a certain degree of risk or injury and that Okaloosa County or the Okaloosa Junior Lifeguard Association
will not be liable for medical expenses or other claims for damages based upon injury to the participant as a
result of his/her participation in these sports or recreational activities. Accordingly, any insurance protection
that the participant may want or need must be obtained by the participant himself/herself or by the parent or
guardian.
Legal Guardian Name
I have read the above and understand it and hereby agree that I will not hold Okaloosa County liable for any
injuries that may occur as a result of participation in the recreation activities provided by Okaloosa County.
Signature: __________________________________________ Date: ______________________________
***200 Meter Swim Test will be conducted May 13th, 20th, and 27th for both sessions 10am at the
boardwalk tower on Okaloosa Island/ Application and Tuition due the day of swim test***
Please Circle the Sessions Desired:
Session 1- $225: June 12th -June 23th
Session 2- $225: July 10th -July 21nd
Enhanced Session (Both 1 and 2) $300
Advance Session- $300 June 12h -July 21nd
Registration Fee: $____________ Paid by: Cash__ Check__
Session 1 and 2 will begin at 8am and end by noon; Advanced will be from noon till 4pm.
We will meet at the Beach Safety Head Quarters at the
Boardwalk on Miracle Strip Parkway next to Anglers on Okaloosa Island for the start of each day.