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Lifeguard Return Form

First Name
Last Name
Address1
City
State
Zip
Email
Cell Phone Number
License Plate Number
Upload a copy of your Valid Vehicle Vegistration
Click here to vehicle registration sample
Title/Position:
Your 2022 Beach Location:
Pre-Season Dates: (List Dates Available (if any)
May 27, 28-29; June 3-4, 10-11, 17-18
Employment* (Start Date):
Employment* (Start Date):
(End Date):
(End Date):
Date of Birth:
Date of Birth:
* Working papers are required for those 16-18 years old EVERY year
Has any name/address change?
1. Yes
2. No
Has any payroll/banking change?
1. Yes
2. No
MEDICAL HISTORY
Have you sustained or do you carry any illness, injury or limiting disability that may affect your ability to complete any physical components of the lifeguard duties required?
1. Yes
2. No
If yes, explain:
EMERGENCY CONTACT
First & Last Name
EMERGENCY CONTACT Relationship:
EMERGENCY CONTACT Phone Number
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Recertification Class Schedules
http://www.southamptontownny.gov/DocumentCenter/View/19602/CP-19602-Recertification
* Required to renew EVERY season by the Town of Southampton
Click here to register for Orientation, CPR & Lifeguard Recertification
https://southamptonrecreation.net/CourseActivities.aspx?id=4&cat=2
(Mandatory) Orientation Dates are:
June 13^th 5:30pm to 8pm
(Required) CPR & Lifeguard Recertification
Lifeguard Certification Expiration Date:
Lifeguard Certification Expiration Date:
Lifeguard Certification Expiration Date:
Lifeguard Certification Expiration Date:
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