2015 / 2016 WATER SAFETY INSTRUCTOR REGISTRATION FORM
(Submit form to Jeremy Post jeremyp@baylorhealth.edu. Payment can be made over the phone 214-820-7946 or online)
PARTICIPANT’S INFORMATION
Participant’s Name:
Age:
Street Address:
City:
Participant’s Phone:
Participant’s Email:
How did you hear about us? (Please select one)
☐ American Red Cross
☐ Landryfitness.com
☐ Returning Student
☐ City of: _______
☐ Facebook
☐ Friend
☐ Other _______
☐ Employer: _______
Sex:
Date of Birth:
State:
Zip:
Facility, Organization or City interested in for employment (may list multiple or leave blank if unsure):
EMERGENCY CONTACT INFORMATION
Emergency Contact Name:
Relation to the Participant:
Home Phone:
Cell Phone:
CLASS SELECTION
Water Safety Instructor
2015 ($275)
Water Safety Instructor
2015 cont…
Water Safety Instructor
2016 ($275)
Class sessions are held
Wednesday - Saturday except for
classes marked with an *, which
indicates different days and/or
times.
☐ December 21 – 23 *
*Class times:
Mon-Wed 9:00am-4:00pm
Class sessions are held
Wednesday - Saturday except for
classes marked with an *, which
indicates different days and/or
times.
Wednesday
Thursday
Friday
Saturday
6:30pm-10:00pm
6:30pm-10:00pm
6:30pm-10:00pm
9:00am-3:00pm
Wednesday
Thursday
Friday
Saturday
6:30pm-10:00pm
6:30pm-10:00pm
6:30pm-10:00pm
9:00am-3:00pm
Session Dates
☐ January 27-30
☐ May 6-9
☐ May 28-31
☐ March 14-16*
*Class times:
Mon-Wed 9:00am-4:00pm
☐ October 28-31
☐ March 23-26
☐ November 18-21
☐ April 27-30
Please confirm that you have read and understand the
following information posted on our website:
I __________ hereby enroll myself in the water safety instructor program. I
waive all claims against the BTLFC, the Baylor Health Care System and any
of its affiliates, including all employees of each entity. I have no current
health problems that would prevent me from participating fully in this
program. I hereby give consent to be medically treated for injury or illness if
the need arises while I am attending class.
I have read and understand the course pre-requisites ☐
I have read through the Frequently Asked Questions ☐
Signature (Parent’s if minor): __________________