Printed from ChabadBronx.org

Lifeguard Registration Form

Lifeguard Registration Form

 Email
Lifeguard Information
Last Name
First Name
Home Address
City
State
Zip
Home phone
Cell Phone
 
Email
Date of Birth
Social Security
Citizenship
USA Other - 
 Specify
Completed 12th Grade
 

 
 
 
Certification
Are you First Aid certified?
Yes No
If yes, when does it expire? (If yes, Send the form by email to Camp@ChabadRiverdale.org)
Are you CPR certified?
Yes No
If yes, when does it expire? (If yes, Send the form by email to Camp@ChabadRiverdale.org)  
Do you have a driver’s license?
Yes No 
If yes, how many years have you been driving?
      
Experience
Have you worked with children before? Yes No

Please write your last three years of experience in Summer Camps, Schools, etc...your position and phone number as a reference.

Company Name
Position
Name of Reference & Contact Number
Company Name
Position
Name of Reference & Contact Number
Company Name
Position
Name of Reference & Contact Number

Emergency Contact Information

Contact 1
Phone
Relationship to Applicant
Are there any medical concerns that we should be aware of?
Contact 2
Phone
Relationship to Applicant
Parent's Daytime Phone
Parent's Daytime Phone
Parent's Daytime Phone
Family Physician
Phone
Address

Tee Shirts
T-shirts can shrink and tend to run small. When in doubt, order the next size. You will be required to wear a camp T-shirt every camp day.
SIZE:  Small Medium Large Extra Large
SLEEVE LENGTH: Short Sleeves Long Sleeves

Signatures

I understand that Camp Gan Israel of Riverdale, has accepted me as a member of their staff and they will not replace me with someone else nor renege on their commitment. Similarly, once I have verbally committed to being a counselor at Camp Gan Israel of Riverdale, I will not be available to be hired elsewhere, nor will I renege on my commitment.

Counselor's Signature   Date
(if under 18) Parent/Guardian  Date
 Email