Demonstrate an understanding of:

LIFESAVING SOCIETY

ociety
The Lifeguarding Experts

e
d organizing

Lifesaving S
uality servic
ties of the

agement
Aquatic Supervisory

ervisor
s checked

skills

tion
k
Training

Managing ris
Responsibili

Facility man

Communica
aquatic sup

Planning an
Supervisory

Providing q

Role of the
Evaluation
Motivation
Date of birth

Prerequisite
Please print each candidate’s name,

Result
and contact information 1 2 3 4 5 6 7 8 9 10
1
Name
Year
Address
Month
City Postal Code
Current Lifesaving Instructor - Earned at (location): Date:
E-mail Phone Day OR Current National Lifeguard - Earned at (location): Date:
2
Name
Year
Address
Month
City Postal Code
Current Lifesaving Instructor - Earned at (location): Date:
E-mail Phone Day OR Current National Lifeguard - Earned at (location): Date:
3
Name
Year
Address
Month
City Postal Code
Current Lifesaving Instructor - Earned at (location): Date:
E-mail Phone Day OR Current National Lifeguard - Earned at (location): Date:

4
Name
Year
Address
Month
City Postal Code
Current Lifesaving Instructor - Earned at (location): Date:
E-mail Day OR Current National Lifeguard - Earned at (location): Date:
Phone
5
Name
Year
Address
Month
City Postal Code
Current Lifesaving Instructor - Earned at (location): Date:
E-mail Phone Day OR Current National Lifeguard - Earned at (location): Date:

6
Name
Year

Address
Month
City Postal Code
Current Lifesaving Instructor - Earned at (location): Date:
E-mail Phone Day OR Current National Lifeguard - Earned at (location): Date:

Permanent cards are mailed directly to successful candidates.

Please ensure addresses are legible and complete. - Satisfactory Performance F - Fail Total Pass Total Fail

Instructor information Exam information

Instructor’s name ID# (optional) Exam date:
YY MM DD
E-mail address ( )
( )
Facility name (e.g., name of pool) Telephone
Telephone Signature
Awards information Awards issued by affiliate Awards not issued This section to be completed by the Aquatic Supervisory Training Instructor
who examined the candidates.
Payment information Exam fees attached Exam fees not attached
Send invoice or receipt to: Examiner’s name ID# (optional)
( )
Host name (Affiliate) Telephone
E-mail address
Street address
( )
City Prov. Postal code Telephone Signature