Eastern Region Intermediate Lifeguard Pilot Pogramme- Instructor & Mentor Application Form

1. Applicant Details

Before submitting your application for selection as an Instructor or Mentor for the Eastern Region Intermediate Lifeguard Pilot Programme, please ensure you have read the selection process.

Question Title

* 1. Please indicate what position you wish to apply for

Instructor

Mentor

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* 2. First Name

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* 3. Last Name

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* 4. SLSNZ Membership Number

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* 5. Club

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* 6. Club

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* 7. Date of Birth

DD/MM/YYYY

Date

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* 8. Gender

Male

Female

Eastern Region Intermediate Lifeguard Pilot Pogramme- Instructor & Mentor Application Form

1. Applicant Details

Question Title

* 1. Please indicate what position you wish to apply for

Question Title

* 2. First Name

Question Title

* 3. Last Name

Question Title

* 4. SLSNZ Membership Number

Question Title

* 5. Club

Question Title

* 6. Club

Question Title

* 7. Date of Birth

Question Title

* 8. Gender

Question Title

* 9. Email Address

Question Title

* 10. Contact number (cell phone)