Eastern Region Intermediate Lifeguard Pilot Programme

1. Applicant Details

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20% of survey complete.

This is an application form for the Intermediate Lifeguard Pilot Programme for the Eastern Region to be held on the 31st January 2015 to 1st February 2015. Before submitting your application, please check that you have all the required pre-requisites. Please ensure you complete the application in full as unfinished applications will not be accepted.

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* 1. Please complete the following personal details:

First Name

Surname

SLSNZ Membership Number

Postal Address

Phone Number

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* 2. Date of Birth

DOB:

Date

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* 3. Gender

Male

Female

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* 4. Please identify your club

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* 5. Please complete emergency contact details

Name

Phone Number

Relationship