AVON JUNIOR LIFEGUARDS 2010

NAME _____________________________________________

PARENT / GUARDIAN ________________________________

ADDRESS __________________________________________

CITY/ ST / ZIP _______________________________________

DATE OF BIRTH _____________________________________

PHONE – BEST ______________________________________

PHONE – OTHER _____________________________________

EMAIL ______________________________________________

UNIFORM SIZES – CIRCLE ONE SIZE FOR EACH ITEM

Shorts: Youth S, M, L    OR    Adult  S, M, L, XL, XXL

Rashguards:  Adult XS, S, M, L, XL, XXL

By signing and returning this form, I hereby agree to permit my child to

participate in the activity indicated above.  Further, I agree to assume

responsibility and liablity  for any injury or illness resulting from said

activity.  My child is to properly conduct him or herself and obey all of the

instructions given by the Junior Guard Instructors.

______________________________________________        ____________

SIGNATURE OF PARENT/GUARDIAN                        DATE

EMERGENCY INFORMATION:

Please indicate the names, addresses anad phone numbers of the two

people to be notified in case of an emergency.  In an extreme emergency

the Avon First Aid will be called.

1. ____________________________________________________________

      Name                                           Address                                       Phone

2. ____________________________________________________________

      Name                                           Address                                       Phone

If there is any medical information you believe the instructors should

be aware of please indicate below.

_____________________________________________________________

_____________________________________________________________