APPLICATION PACKET
INSTRUCTIONS
Please read all instructions before
completing the application packet.
q
JG Program
Application – Complete all
items. Please remember to sign and
date.
q
Authorization of
Consent to Treatment of a Minor – All
physician and health insurance information must be complete. Only one parental/guardian signature is
required for this form.
q
Press & Photo
Release – Only one parent/guardian
signature is required for this form. If
you choose not to sign, please write, “DENIED” across form and initial.
q
Physician’s Release
Form – Your physician must complete
form.
PLEASE NOTE: The Physician’s Release Form must be returned WITH THE
APPLICATION or ON the first
day of the program. Do NOT mail it in separately! If the Junior Guard does not turn in the release form by the
first day of the session, he/she will
not be able to participate in any activities until the form is received. ***NO COPIES OR FACSIMILES***
Return the Application, Consent to Treat and Press/Photo
release, along with $250.00 program
fee** to:
Junior Lifeguard Program
**Checks, credit card or
money orders only – make checks payable to:
L.A. Co. P & R
Applications must be RECEIVED no later than
Registration is not
guaranteed until all forms (except Physician’s Release), along with program fee
are received. Applications will be
processed as they are received. If
information is missing, registration will be delayed.
Financial Aid is available,
contact the program director at (661)257-4050 for details.
Please note: As of this
printing the voice mail system is non-operational.
DEPARTMENT OF PARKS AND RECREATION
JUNIOR LIFEGUARD PROGRAM 2005
Please fill out all pages
of this application in ink and
return the completed forms.
Name____________________________________________________ SESSION: ____________________
Address________________________________________ City
_________________________________State____
Zip Code__________________ Home
Phone_( )______________________Cell
Phone (______)____________________
Birth Date ______/______/_______ Age________
Height________
Weight________ Sex: M
F
Mother’s Name______________________________________ Father’s
Name_______________________________________
Mother’s Work #_(
)______________________________
Father’s Work #_(
)_______________________________
Guardian’s Name (if applicable)_________________________________________ Phone( )_________________________
In the event of an emergency, when a parent is unavailable, please
provide the name and number of a reliable friend or relative that may be
contacted.
Name__________________________________________________ Phone #___________________________________________
**************************************************************************************************************
LIABILITY WAIVER: In
consideration of my child being allowed to participate in the Los Angeles
County Department of Parks and Recreation Junior Lifeguard Program, I do
hereby, for myself, my child, my heirs, and executors waive, release and
forever discharge any and all rights and claims for damages which may,
hereafter, accrue to me against the County of Los Angeles and each of its
officers, agents and employees for any and all injuries sustained out of my
child’s association with, entry in, participation on, or traveling to and from
said Junior Lifeguard Program at Castaic Lake Recreation Area.
I also understand that any
behavior deemed unacceptable by instructors will result in the participant
being dropped from the program without a refund. No minor will be permitted to attend the Junior Lifeguard Program
at
_____________________________________________________________________ _________________________________
Parent or Guardian Signature Date
The fee for
the program is $250.00. Please make checks payable to
METHOD OF PAYMENT: DO
NOT SEND CASH
CHECK ________ VISA________MASTERCARD ________DISCOVER__________
CARD #_______________________________________EXP DATE _______________
CARDHOLDER’S
SIGNATURE___________________________________________________
If credit card billing address differs from mailing address, please
note-billing address in space above.
*************************************************************************************************************
FOR OFFICE USE ONLY
AMOUNT DUE $____________ AMOUNT
PAID:$____________ DATE
PAID:________________
CHECK#________________ CHECK
NAME_____________________________________________
VISA________
M/C_________ DISC_________ REF#_____________________________
DRIVER’S LICENSE
#:_______________________ RECEIPT
#:____________________________
DEPARTMENT OF PARKS AND RECREATION
JUNIOR
LIFEGUARD PROGRAM 2005
AUTHORIZATION
OF CONSENT TO TREATMENT OF MINOR
I (We) the
undersigned, parent(s)/guardian(s) of_____________________, a minor, do hereby
authorize all representatives of the Los Angeles County Department of Parks and
Recreation as agent(s) for the undersigned, to consent to any examination,
X-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care
which is deemed advisable by and rendered under the general or special
provision of any physician and surgeon licensed under the provisions of the
Medical Practice Act or the medical staff of any accredited hospital, but is
given to provide authority and power on the part of our aforesaid agent(s) to
give specific consent to any and all such diagnosis, treatment or hospital care
which the aforementioned physician in the exercise of his best judgment may
deem advisable.
It is understood that
effort shall be made to contact the undersigned prior to the rendering of
treatment to the patient, but that none of the above treatments shall be
withheld if the undersigned cannot be reached.
This authorization
shall remain effective through 2005 Junior Lifeguard Program Sessions, unless
sooner revoked in writing and delivered to said agent(s).
Parent’s Name (please
print) ___________________________________________________________
Parent’s
Signature_______________________________
Daytime Phone #_____________________
Guardian’s Name
(please print)__________________________________________________________
Guardian’s
Signature____________________________
Daytime Phone #_____________________
Date_________________________________________________________________________________
IN COMPLIANCE WITH
CONSENT MANUAL,
Physician’s
Name_____________________________
Phone #_________________________________
Insurance
Carrier_____________________________
Policy #________________________________
Insured’s
Name________________________________
Insured’s ID#___________________________
MEDICAL
INFORMATION: Please include known
allergies, allergic reactions, special medications, medical
problems/conditions. If none exist,
please write NONE in the space below.
_____________________________________________________________________________________
_____________________________________________________________________________________
THE ABOVE MUST BE
FILLED OUT COMPLETELY AND SIGNED FOR YOUR CHILD TO REGISTER AND PARTICIPATE IN
THE JUNIOR LIFEGUARD PROGRAM.
DEPARTMENT OF PARKS AND RECREATION
JUNIOR
LIFEGUARD PROGRAM 2005
PHYSICIAN’S
RELEASE FORM
Name of
Applicant_______________________________________________________
Address______________________________
City_____________________________
State_________
Zip Code____________ Home Phone #_______________________
Sex: M
F Age_____________
Height_____________ Weight ___________
Pulse_________________
B/P_______________ Temperature___________________
TO THE PHYSICIAN:
The person you are examining
is an applicant for the Junior Lifeguard Program at
EXAMINATION RESULTS:
The applicant named above
is:(Circle One) ABLE / NOT ABLE to
participate in the Junior Lifeguard Program.
APPLICANT’S CONDITION:
(Check One): ____ Excellent____ Good ____Fair
RESTRICTIONS:
________________________________________________________
________________________________________________________________________
RECOMMENDATIONS:
__________________________________________________
________________________________________________________________________
________________________________________ _______________________
SIGNATURE OF EXAMINING
PHYSICIAN DATE
OFFICE STAMP:
(Must be stamped)
DEPARTMENT OF PARKS AND RECREATION
JUNIOR
LIFEGUARD PROGRAM 2005
PRESS AND PHOTO RELEASE
I understand that my child may
be photographed while participating in the Los Angeles County Department of
Parks and Recreation Junior Lifeguard Program.
I agree to allow these photos to be used for promotional purposes
without any monetary compensation and I understand that these photos will be
the property of
Department of Parks and
Recreation Junior Lifeguard Program.
Only one signature
is required.
Parent or Guardian’s
Name (please print)
_________________________________________
Parent or Guardian’s
Signature
__________________________________________________