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Boca Raton Classes
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Course Selection
Course Location
Start Date
End Date
Lifeguard Training
YMCA of Boca Raton
6631 Palmetto Cir S
Boca Raton, FL 33433
MEET IN THE POOL AREA
September 17, 2010
September 25, 2010

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In the event courses are cancelled by participants, deposits will be forfeited and remaining balances will be credited to future courses. Refunds will be given if courses are cancelled by Rescue 101, LLC, unless courses can be rescheduled. Classes missed cannot be made up and refunds will not be given.
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 Student Information  Mailing Address
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First Name :
Address :
Last Name :
City :
Company Name :
Sate :
Zip:
Phone :
Email :
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 Emergency Contact Information  Medical Conditions
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Main Contact :
  Briefly describe your condition:
Email :
Phone :
Relationship :
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Referred by:
Please enter the name of the person that referred you:
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I, the above listed applicant and/ or parent/ guardian of the above listed individual, agree to participate and/or permit my child(ren) to participate in the above indicated training course(s) conducted by Rescue 101, LLC through their network of certified trainers. I will not hold accountable the instructors and staff of Rescue 101, LLC for any injury that may occur to myself, my child(ren), or others listed on this form. I agree to indemnify and hold harmless the mentioned, their instructors and staff against any and all liability for personal injury, including injuries resulting in death, damage to property, or both while I, my child(ren), or others listed on this form are participating in any program provided by Rescue 101, LLC. I further agree to reimburse the above parties for any damages they are compelled to pay arising from any claims, demand, action or cause of action by myself, my child(ren), or others listed on this firm. I have noted on this form any medical history or problems of which the instructor and/or staff should be aware of that would or could effect participation in any of the programs provided by Rescue 101, LLC.
 
Birth Date :   Enter Your Initials :    
    MM/DD/YYYY
Date & Time:  
9/6/2010 3:18:43 AM
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