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American Red Cross
Lifeguard Courses Spring 2024

Sullivan County Parks & Recreation Department

American Red Cross Lifeguard Courses Spring 2024
Sullivan County Parks, Recreation & Beautification Department
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Courses taught at Fallsburg Jr./Sr. High School, Fallsburg, NY
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Register at the Parks & Recreation Department in the Monticello Government Center or online at https://www.surveymonkey.com/r/SCPARKS-LGCOURSES2024.
Payments can be made by check, cash, or card at the
Monticello Government Center.
Cards can be taken over the phone at 845-807-0287. Checks or cash can be mailed to 100 North Street, Monticello, NY 12701.
Checks must be payable to “Sullivan County Treasurer”.

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* 1. Course Options
Select Course:

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* 2. Student First & Last Name:

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* 3. Student Date of Birth:

Date

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* 4. Student Phone Number:

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* 6. Student Address:

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* 7. If the student is under 18,
Parent/Legal Guardian Name:

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* 8. If the student is under 18,
Parent/Legal Guardian Phone Number:

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* 9. Emergency Contact First & Last Name:

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* 10. Emergency Contact Phone Number:

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* 11. Do you have any special needs or accommodations?

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* 12. I understand that I must be 15 years or older by the last day of the course.

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* 13. I understand that this is a Blended Learning course where I will be required to complete online work in advance prior to the first in-person session of the course.

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* 14. I understand that the prerequisite swim tests will be given before the first in-person session of the course or at the first in-person session of the course and I must pass them in order to participate in the Lifeguard or Lifeguard Recertification Course.

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* 15. I give my permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of the County of Sullivan, New York, United States of America. I agree that the County of Sullivan maintains ownership of such pictures, etc., including the copyright, and may use them for any purpose consistent with County of Sullivan governmental activities. These uses include (but are not limited to) illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet.

I acknowledge that I will not receive any compensation or other consideration for the use of such pictures, etc., and hereby release the County of Sullivan and its agents and assigns from any and all claims which arise out of or are in any way connected with such use. I or my parent/legal guardian have read and understood this consent and release. I give my consent to the County of Sullivan to use my name and likeness in the above-described manner.


I am 18 years of age or I am the parent or guardian of a minor taking the course.

I hereby acknowledge that any training, demonstration, and participation in this program may involve certain risks to any participant. I fully understand these risks and voluntarily wish to have self/minor take the course selected.

In consideration of self/minor being permitted to participate in the course, I hereby agree to assume all the risks and responsibilities surrounding such participation, including, without limitation, those of injury to person or personal property; and further, for self/minor, my heirs, personal representatives, and assignees. I hereby agree to defend, hold harmless, indemnify, release forever, and forever discharge the County of Sullivan and all their employees from and against any and all threatened and imposed claims, demands, and actions or causes of action, on account of damage to personal property, or personal injury which may result from the aforesaid participation and activities incident thereto. Further, it is hereby certified that the above-named participant has no medical or psychological conditions which would preclude such participation. I hereby authorize the County of Sullivan through its authorized agents to secure for self/minor any emergency medical treatment that becomes or that may become necessary as a result of participation in course.

I acknowledge I have read and understand this information.

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