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LIFEGUARD for a DAY - Permission Slip
Permission, Liability, Swim Assessment & Media Release Waiver
Organisation: Clarence Valley Regional Aquatic Centre
Program: Lifeguard for a Day
Program Dates: Tuesday, 14 July 2026
Program Time: 9am – 3pm
Youth aged 15–18 years
*
1.
PARTICIPANT INFORMATION
(Required.)
Name:
DOB:
Parent/Guardian:
Phone:
Email:
Emergency Contact / Phone:
*
2.
PERMISSION & MEDICAL FITNESS
I certify the participant is physically able to engage in aquatic and physical activities, including swimming, water safety training, and leadership exercises.
(Required.)
Yes
No
*
3.
I have disclosed any medical conditions, allergies, injuries, or medications:
(Required.)
*
4.
I authorise program staff to obtain emergency medical care if needed.
(Required.)
I do.
*
5.
SWIMMING ABILITY & WATER CONFIDENCE
Minimum in-water participation requirement:
(Required.)
Swim 50 meters continuously
Tread water 1 minute
Submerge head and recover comfortably
*
6.
Self-reported skill level:
(Required.)
Beginner
Intermediate
Advanced
Strong Swimmer
*
7.
LIABILITY RELEASE
I voluntarily assume all risks of participation, including injury, illness, or water-related hazards. I release and hold harmless the organization, staff, volunteers, and facility operators from any claims or damages arising from participation, except in cases of gross negligence or wilful misconduct.
(Required.)
I do.
*
8.
PHOTO & MEDIA RELEASE
I grant permission for images or video of the participant to be used for educational, promotional, social media, or website purposes.
(Required.)
Yes, permission granted.
No, I do not give permission.
