Core Pool Option

servation

& carry
ured victim

covery
tation
d victim
practice

victim

ition

arry

rill
ositioning & ro

dard: approach
missing person

ard: rescue d
dard: object re
scanning & ob

ing situations
dard: spinal c
victim recogn
t of submerge
t of drowning

of spinal-inj
n

n
LIFESAVING SOCIETY

mmunicatio

mmunicatio
theory and

chniques
ovals
The Lifeguarding Experts

Entries and rem

checked

Physical stand
National Lifeguard:

Supervision: p

Specialized te

Pool lifeguard
Pool analysis

Physical stan

Physical stan

Physical stan
Management
Managemen
Managemen

Pool search:
Lifeguarding

Lifeguard co

Supervision:
Lifeguard co

Supervision:
Pool (Revised 2004)

s
Date of birth

Prerequisite
Gender
Side 1: Please print each candidate’s

Result
*1 *2a *2b *3a *3b *3c *4 *1 *2a *2b *3 *4 *5 *6a *6b *6c *6d 7
name and contact information legibly. * Items are instructor evaluated
1 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
2 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
3 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
4 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
5 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
6 M F
Name
Year

Address
Month
City Prereq.:
Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:

* Check box if there are more candidates on the reverse side of this page.
This test sheet is Page of Pages.
- Satisfactory Performance F - Fail Total Pass
for Exam
Total Fail
for Exam

Instructor information Exam information Exam is:

Instructor’s name ID# Exam date: * Original OR * Recert
YY MM DD
E-mail address ( )
( )
Facility name (e.g., name of pool) Telephone
Telephone Signature
Awards information Awards issued by affiliate Awards not issued This section to be completed by the NLS Examiner who examined the
candidates.
Payment information Exam fees attached Exam fees not attached
Send invoice or receipt to: Examiner’s name ID#
( )
Host name (Affiliate) Telephone
E-mail address
Street address
( )
City Prov. Postal code Telephone Signature
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.
 Core Pool Option

servation

& carry
ured victim

covery
tation
d victim
practice

victim

ition

arry

rill
ositioning & ro

dard: approach
missing person

ard: rescue d
dard: object re
scanning & ob

ing situations
dard: spinal c
victim recogn
t of submerge
t of drowning

of spinal-inj
n

n
LIFESAVING SOCIETY

mmunicatio

mmunicatio
theory and

chniques
ovals
The Lifeguarding Experts

Entries and rem

checked

Physical stand
National Lifeguard:

Supervision: p

Specialized te

Pool lifeguard
Pool analysis

Physical stan

Physical stan

Physical stan
Management
Managemen
Managemen

Pool search:
Lifeguarding

Lifeguard co

Supervision:
Lifeguard co

Supervision:
Pool (Revised 2004)

s
Date of birth

Prerequisite
Gender
Side 2: Please print each candidate’s *1 *2a *2b *3a *3b *3c *4 *1 *2a *2b *3 *4 *5 *6a *6b *6c *6d 7
name and contact information legibly. * Items are instructor evaluated
7 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
8 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
9 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
10 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
11 M F
Name
Year
Address
Month Prereq.:
City Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:
12 M F
Name
Year

Address
Month
City Prereq.:
Postal Code Bronze Cross Date earned: Location:
Original:
Standard 1st Aid Date earned: Location:
E-mail Phone Day Recert: NLS Date earned: Location:

* Check box if there are more candidates on the reverse side of this page.
This test sheet is Page of Pages.
- Satisfactory Performance F - Fail Total Pass
for Exam
Total Fail
for Exam

Exam information Exam is:

( )
Exam date: * Original OR * Recert
YY MM DD
Host name (Affiliate) Telephone ( )
Facility name (e.g., name of pool) Telephone
This section to be completed by the NLS Examiner who examined
the candidates.
Please complete Instructor, Awards and Payment information sections on
Side 1 of test sheet. Host name, Exam information and Examiner
Examiner’s name ID#
sections must be completed on both sides 1 and 2 of the test sheet.

E-mail address

( )
Telephone Signature
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.