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Name Address Postal Code City E-mail Phone 2 3 Name Address Postal Code City E-mail Phone 4 Name Address Postal Code City E-mail Phone 5 Name Address Postal Code City E-mail Phone 6 Name Address Postal Code City E-mail Phone Name Address Postal Code City E-mail Phone 1 The Lifeguarding Experts LIFESAVING SOCIETY Dt f ir ae o b th R ut es l Fit es chall nge n s e k sp t& v t Wal , o e alua e c :ijr Res ue 4 n u ed victim es ue 3 w sc ers R c :t o re u e u e R sc e 2: submerg d victim Rescue 1: ult ple victims m i Team search l nu n e Spina i j ry ma ag ment Hy othe mi p r a t ce i y: c s o s vi t Obs ru t d a rwa un on ci u c im O struc ed airway on cious infant b t :c s Obstructed airway: u t conscio s adul or child Two-rescuer CPR ne r scu r O -e e CPR r a a s n Fi st id sse sme t Endur n ch llen e a ce a g Rescue drill *1 *2 *3 *4 *5 *6 *7a *8 *9 10 *11 12 13 *14 15 *7b *7c * Items are instructor evaluated Examiner’s name ID# Telephone ( ) Signature E-mail address This section to be completed by the Lifesaving Examiner who examined the candidates. Send invoice or receipt to: City Prov. Postal code Street address Telephone Host name (Affiliate) ( ) Exam fees attached Exam fees not attached Payment information Awards issued by affiliate Awards not issued Awards information Facility name (e.g., name of pool) Telephone ( ) Exam information YY MM DD Exam date: Exam is: Original OR Recert * * Return completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail. Telephone ( ) Signature Instructor’s name ID# E-mail address Instructor information - Satisfactory Performance F - Fail Total Fail for Exam Total Pass for Exam Check box if there are more candidates on the reverse side of this page. * This test sheet is Page of Pages. Side 1: Please print each candidate’s name, and contact information legibly. Bronze Cross (Revised 2003) Prereq.: Bronze Cross Date earned: Location: Original: Location: Bronze Medallion Date earned: Location: Emergency 1st Aid Recert: Date earned: Prereq.: Bronze Cross Date earned: Location: Original: Location: Bronze Medallion Date earned: Location: Emergency 1st Aid Recert: Date earned: Prereq.: Bronze Cross Date earned: Location: Original: Location: Bronze Medallion Date earned: Location: Emergency 1st Aid Recert: Date earned: Prereq.: Bronze Cross Date earned: Location: Original: Location: Bronze Medallion Date earned: Location: Emergency 1st Aid Recert: Date earned: Prereq.: Bronze Cross Date earned: Location: Original: Location: Bronze Medallion Date earned: Location: Emergency 1st Aid Recert: Date earned: Prereq.: Bronze Cross Date earned: Location: Original: Location: Bronze Medallion Date earned: Location: Emergency 1st Aid Recert: Date earned: Prerequisites checked Year Year Year Year Year Year Month Month Month Month Month Month Day Day Day Day Day Day

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Page 1: g n c a g c v n e r u a e r s e R y o y l n p l e d g l e ... · PDF filen g e n s e k u s p t & h v t W a l, o r e a l u a e c: i j r R e s 4 n u e d v i c t i m 3 w s c e r s t o

Name

Address

Postal Code City

E-mail Phone

2

3

Name

Address

Postal Code City

E-mail Phone

4

Name

Address

Postal Code City

E-mail Phone

5

Name

Address

Postal Code City

E-mail Phone

6

Name

Address

Postal Code City

E-mail Phone

Name

Address

Postal Code City

E-mail Phone

1

The Lifeguarding Experts

LIFESAVING SOCIETY

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*1 *2 *3 *4 *5 *6 *7a *8 *9 10 *11 12 13 *14 15*7b *7c* Items are instructor evaluated

Examiner’s name ID#

Telephone

( )

Signature

E-mail address

This section to be completed by the Lifesaving Examiner who examined the candidates.

Send invoice or receipt to:

City Prov. Postal code

Street address

TelephoneHost name (Affiliate)

( )

Exam fees attached Exam fees not attachedPayment information

Awards issued by affiliate Awards not issuedAwards information

Facility name (e.g., name of pool) Telephone

( )

Exam information

YY MM DDExam date:

Exam is:

Original OR Recert* *

Return completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.

Telephone

( )

Signature

Instructor’s name ID#

E-mail address

Instructor information

- Satisfactory Performance F - FailTotal Failfor Exam

Total Passfor Exam

Check box if there are more candidates on the reverse side of this page.*This test sheet is Page of Pages.

Side 1: Please print each candidate’s name, and contact information legibly.

Bronze Cross (Revised 2003)

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Pre

requ

isite

s ch

ecke

d

Year

Year

Year

Year

Year

Year

Month

Month

Month

Month

Month

Month

Day

Day

Day

Day

Day

Day

Page 2: g n c a g c v n e r u a e r s e R y o y l n p l e d g l e ... · PDF filen g e n s e k u s p t & h v t W a l, o r e a l u a e c: i j r R e s 4 n u e d v i c t i m 3 w s c e r s t o

Name

Address

Postal Code City

E-mail Phone

Name

Address

Postal Code City

E-mail Phone

Name

Address

Postal Code City

E-mail Phone

Name

Address

Postal Code City

E-mail Phone

7

8

9

10

11

12

Name

Address

Postal Code City

E-mail Phone

Name

Address

Postal Code City

E-mail Phone

The Lifeguarding Experts

LIFESAVING SOCIETY

Year

Year

Year

Year

Year

Year

Month

Month

Month

Month

Month

Month

Day

Day

Day

Day

Day

Day

Dt

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*1 *2 *3 *4 *5 *6 *7a *8 *9 10 *11 12 13 *14 15*7b *7c* Items are instructor evaluated

Examiner’s name ID#

Telephone

( )

Signature

E-mail address

This section to be completed by the Lifesaving Examiner who examined the candidates.

Facility name (e.g., name of pool) Telephone

( )

Exam information

YY MM DDExam date:

Exam is:

Original OR Recert* *

Return completed test sheet to the Lifesaving Society Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.

Please complete Instructor, Awards and Payment information sections on Side 1 of test sheet. Host name, Exam information and Examiner sections must be completed on both sides 1 and 2 of the test sheet.

TelephoneHost name (Affiliate)

( )

Side 2: Please print each candidate’s name, and contact information legibly.

Bronze Cross (Revised 2003)

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

Prereq.:

Bronze Cross Date earned: Location:

Original:Location: Bronze Medallion Date earned:Location: Emergency 1st Aid

Recert:

Date earned:

- Satisfactory Performance F - FailTotal Failfor Exam

Total Passfor Exam

Check box if there are more candidates on the reverse side of this page.*This test sheet is Page of Pages.