Side 1: Please print each candidate - PDF document

Side 1: Please print each candidate’s name and contact information legibly. Bronze Medallion D oatef birth Rutesl Walk,o &msrae spt deon escue 3: open waterR esue2 onbretig victimRc :n-ahn Sarceh lnunenSpina ijry maagmet Circ. mrg: hokEesc arCirc. Emerg: heart attck o angina Circ. Emrg: externl bleedingea rc tkCi.Emerg: sroe & TIA tceiy cssObsrutd arwa: unonciou One-escer CPR: adult &cldru hi Endurane challengec Finess chllengeta scue drillRe ruSelf-esce hwin aurcyTrogcca 1 Year Year Year Year Year Year Month Month Month Month Month Month Day Day Day Day Day 2 3 4 5 6 *1 *2 *3 *4 *5 *6 *7 *8a *8b *9a *10 11 13 14 15 *9b *9c *9d 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 Name Address Postal Code City E-mail Phone Name Address Postal Code City E-mail Phone The Lifeguarding Experts LIFESAVING SOCIETY (Revised 2003) Prerequisites: Recert: Bronze Medallion Date earned: Location: Location: 13 years old OR Bronze Star Date earned: Original: Prerequisites: Recert: Bronze Medallion Date earned: Location: Location: 13 years old OR Bronze Star Date earned: Original: Prerequisites: Recert: Bronze Medallion Date earned: Location: Location: 13 years old OR Bronze Star Date earned: Original: Prerequisites: Recert: Bronze Medallion Date earned: Location: Location: 13 years old OR Bronze Star Date earned: Original: Prerequisites: Recert: Bronze Medallion Date earned: Location: Location: 13 years old OR Bronze Star Date earned: Original: Prerequisites: Recert: Bronze Medallion Date earned: Location: Location: 13 years old OR Bronze Star Date earned: Original: * 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 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. Rescue 1: on-contactn Defences &releases Prreusits checkdeqiee Obtctedairwy: cnsioussru a oc Day 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 REMOVE ALL DATA 490-8844 490-8844 416 416 asdfasdf asdfasdf 14564654 14564654 sdfasdfs sdfasdfs 416 416 sfgdsfgsdfg sfgdsfgsdfg 12 12 12 12 11 11 456 456 asdfasfda asdfasfda 12 12 12 12 123 123 M2J 1P8 ON asdfasdf adfasdf 4654 416 wdfasdfsadf sfsdfasd 123 10 10 10 416-490-8844 x1523456 nadial@lifeguarding.com m2j 1p8 toronto 400 consumers rd. nadia luck 490-8844 X123456 490-8844 X123456 490-8844 X123456789 490-8844 X123456789