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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
fir
ae
o b
th
Ru
tes
l
Fit
es c
hall
nge
ns
e
k s
pt &
v
tW
al,
o
eal
uae
c
:i
jr
Res
ue4
n
ued
vic
tim
esue
3
w
scer
sR
c
:t
ore
u
eu
eR
sce
2: s
ubm
erg
d vi
ctim
Res
cue
1:
ult p
le v
ictim
sm
i
Team
sea
rch
ln
un
eS
pina
ij
ry m
aag
men
t
Hy
othe
mi
pr
a
tc
ei
y:
cs
os
vit
Obs
rut
d a
rwa
un
onci
uc
im
Ost
ruc
ed a
irway
on
ciou
s in
fant
bt
:c
s
Obs
truct
ed a
irway
: u
t c
onsc
ios
adul
or c
hild
Two-
resc
uer C
PR
ner
scu
r O
-e
eC
PR
r a
as
nFi
stid
sse
sme
t
End
urn
ch
llen
ea
cea
g
Res
cue
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
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
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
fir
ae
o b
th
Ru
tes
l
Fit
es c
hall
nge
ns
e
k s
pt &
v
tW
al,
o
eal
uae
c
:i
jr
Res
ue4
n
ued
vic
tim
esue
3
w
scer
sR
c
:t
ore
u
eu
eR
sce
2: s
ubm
erg
d vi
ctim
Res
cue
1:
ult p
le v
ictim
sm
i
Team
sea
rch
ln
un
eS
pina
ij
ry m
aag
men
t
Hy
othe
mi
pr
a
tc
ei
y:
cs
os
vit
Obs
rut
d a
rwa
un
onci
uc
im
Ost
ruc
ed a
irway
on
ciou
s in
fant
bt
:c
s
Obs
truct
ed a
irway
: u
t c
onsc
ios
adul
or c
hild
Two-
resc
uer C
PR
ner
scu
r O
-e
eC
PR
r a
as
nFi
stid
sse
sme
t
End
urn
ch
llen
ea
cea
g
Res
cue
drill
Pre
requ
isite
s ch
ecke
d
*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.