NLS Waterfront test sheet - Revised 2012 - Lifesaving Society
NLS Waterfront test sheet - Revised 2012 - Lifesaving Society
NLS Waterfront test sheet - Revised 2012 - Lifesaving Society
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<strong>Waterfront</strong><strong>Revised</strong> <strong>2012</strong>Side 1: Please print each candidate’sname and contact information legibly.1Last nameFirst nameGenderDate of birthM FYearPrerequisites checkedLifeguarding theory & practiceRun-swim-tow †Rescue sprint †Victim carry †<strong>Waterfront</strong> facility analysisLifeguard communicationScanning & observationPositioning & rotationInterventionEntries & removalsUse of rescue craft †Skin diving skillsSearch: missing personMgmt: distressed or drowning victim †Mgmt: submerged, non-breathing victim †Mgmt: spinal-injured victim †Mgmt: injured swimmer †Lifeguarding situations †1* 2a* 2b* 2c* 3* 4* 5a* 5b* 5c* 6* 7* 8* 9* 10a* 10b* 10c* 10d* 11* Items are instructor-evaluated † Items are mandatory during recertResultAddressCityProv.Postal CodeMonthE-mailPhoneDayPrereq.:Original:Recert:Bronze Cross Date earned:Standard 1st Aid Date earned:<strong>NLS</strong>Date earned:Location:Location:Location:2 M FLast nameFirst nameYearAddressCityProv.Postal CodeMonthE-mailPhoneDayPrereq.:Original:Recert:Bronze Cross Date earned:Standard 1st Aid Date earned:<strong>NLS</strong>Date earned:Location:Location:Location:3 M FLast nameFirst nameYearAddressCityE-mailPhoneProv.Postal CodeMonthDayPrereq.:Original:Recert:Bronze Cross Date earned:Standard 1st Aid Date earned:<strong>NLS</strong>Date earned:Location:Location:Location:4 M FLast nameFirst nameYearAddressCityProv.Postal CodeMonthE-mailPhoneDayPrereq.:Original:Recert:Bronze Cross Date earned:Standard 1st Aid Date earned:<strong>NLS</strong>Date earned:Location:Location:Location:Check this box if there are more candidates on the reverse side of this page.This <strong>test</strong> <strong>sheet</strong> is Page ________ of ________ PagesInstructor informationInstructor’s nameE-mail addressID#- Satisfactory Performance X - FailExam informationExam date:YY MM DDTotal Passfor ExamExam is:Original ORTotal Failfor ExamRecertTelephoneSignatureFacility name (e.g., name of pool)TelephoneAwards informationPayment informationSend invoice or receipt to:Host name (Affiliate)Street addressAwards issued by affiliate Awards not issuedExam fees attachedExam fees not attachedTelephoneThis section to be completed by the <strong>NLS</strong> Examiner who examined the candidates.Examiner’s nameID#E-mail addressCity Prov. Postal codeTelephoneSignatureReturn completed <strong>test</strong> <strong>sheet</strong> to the <strong>Lifesaving</strong> <strong>Society</strong> Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.
<strong>Waterfront</strong><strong>Revised</strong> <strong>2012</strong>Side 2: Please print each candidate’sname and contact information legibly.5Last nameFirst nameGenderDate of birthM FYearPrerequisites checkedLifeguarding theory & practiceRun-swim-tow †Rescue sprint †Victim carry †<strong>Waterfront</strong> facility analysisLifeguard communicationScanning & observationPositioning & rotationInterventionEntries & removalsUse of rescue craft †Skin diving skillsSearch: missing personMgmt: distressed or drowning victim †Mgmt: submerged, non-breathing victim †Mgmt: spinal-injured victim †1* 2a* 2b* 2c* 3* 4* 5a* 5b* 5c* 6* 7* 8* 9* 10a* 10b* 10c* 10d* 11* Items are instructor-evaluated † Items are mandatory during recertMgmt: injured swimmer †Lifeguarding situations †ResultAddressCityProv.Postal CodeMonthE-mailPhoneDayPrereq.:Original:Recert:Bronze Cross Date earned:Standard 1st Aid Date earned:<strong>NLS</strong>Date earned:Location:Location:Location:6 M FLast nameFirst nameYearAddressCityProv.Postal CodeMonthE-mailPhoneDayPrereq.:Original:Recert:Bronze Cross Date earned:Standard 1st Aid Date earned:<strong>NLS</strong>Date earned:Location:Location:Location:7 M FLast nameFirst nameYearAddressCityE-mailPhoneProv.Postal CodeMonthDayPrereq.:Original:Recert:Bronze Cross Date earned:Standard 1st Aid Date earned:<strong>NLS</strong>Date earned:Location:Location:Location:8 M FLast nameFirst nameYearAddressCityProv.Postal CodeMonthE-mailPhoneDayPrereq.:Original:Recert:Bronze Cross Date earned:Standard 1st Aid Date earned:<strong>NLS</strong>Date earned:Location:Location:Location:Check this box if there are more candidates on the reverse side of this page.This <strong>test</strong> <strong>sheet</strong> is Page ________ of ________ Pages- Satisfactory Performance X - FailExam informationExam date:YY MM DDTotal Passfor ExamExam is:Original ORTotal Failfor ExamRecertHost name (Affiliate)TelephoneFacility name (e.g., name of pool)TelephoneThis section to be completed by the <strong>NLS</strong> Examiner who examined the candidates.Please complete Instructor, Awards and Payment information sections on Side 1of the <strong>test</strong> <strong>sheet</strong>. Host name, Exam information and Examiner sections must becompleted on both sides 1 and 2 of the <strong>test</strong> <strong>sheet</strong>.Examiner’s nameE-mail addressID#TelephoneSignatureReturn completed <strong>test</strong> <strong>sheet</strong> to the <strong>Lifesaving</strong> <strong>Society</strong> Branch Office promptly after the exam. Retain one copy for your records. Do not send cash by mail.
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