2011 Canadian Lifeguard Emergency Response Championship

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2011 Canadian Lifeguard Emergency Response Championship
2011 Canadian Lifeguard Emergency
Response Championship
Registration Package
DATE:
Saturday May 28th – Sunday May 29th 2011
LOCATION:
Surrey Sport & Leisure Complex
COMPETITION:
The competition is sanctioned by the Lifesaving Society Canada and the International Life Saving
Federation. Rules from the ILS Competition Manual (2009 Edition), and the Canadian Competition
Manual (2010 Edition) will be followed for all events, except the Barnsley Relay and Individual First
Aid which are exhibition events, and the rules for those events are within the information
package.
EVENTS:
 Priority Assessment
 First Aid
 Water Rescue
EXHBITION EVENTS: All exhibition events will be co-ed and will require at least one member of the opposite sex on the
competing team.
 Individual First Aid
 4 X 50m Barnsley Relay
AWARDS:
Awards will be issued in accordance with the 2010 Canadian Competition Manual.
ENTRY DEADLINE:
Registration and complete entries must be received by May 19th 2011. No late registration will be
accepted. Registration on or before May 1st 2011 will receive a discount as indicated below.
Registration and entries are considered complete when all of the following has been completed in
full and received at the Lifesaving BC & Yukon Branch:






Registration form
Registration fees paid in full
Waiver and Release Form
Event Entry Form
Copy of each competitor’s current Lifesaving Award
Copy of registered athlete card or registered athlete number
2011 Canadian Lifeguard Emergency Respo nse Champio nship Registration
Page |2
2011 CLERC Registration/Inscription de l’équipe

Contact Information/ Coordoneés pour rejoinder l’équipe
Club or Affiliate/ Nom du club ou Affilié:
 Unattached/Non attaché
Name/Nom:
Coach/Entraîneur ou Manager/Gérant:
Mailing Address/ Adresse postale:
Phone/Téléphone:
City/ville:
Fax/télécopieur:
Province:
Postal Code/Code
postal:
Email/courriel:
Entries will be confirmed by email/Votre inscription vous sera confirmée par courriel. Please print clearly/ Ecrivez lisblement s.v.p.
Registration fees/Frais d’inscription
Description
On or before
May 1/ sur ou
avant 1 de Mai
After May 1/
Aprés 1 de Mai
Competitor Registration/ Inscription par compétiteur
$10/person
$12/person
How Many?
Combien?
Line Total/Total
de cette ligne
Short Sleeve T-shirts/Manches courtes
XS/XP
S/P
M
L/G
XL/TG
XXL/TTG
Event Entry Fees/ Les entrées par épreuve
Individual First Aid – Exhibition Event
Barnsley Relay / Equipe de relais de Barnsley – exhibition
Banquet Ticket / Billet de banquet (Sat May 28)
Payment method/Mode de paiement
$15/shirt
$25/team
$30/team
/event
/event
NO CHARGE NO CHARGE
NO CHARGE NO CHARGE
$50/person
Total
$0.00
$0.00
$0.00



Payment/Paiement
Cheque/Chéque
Money Order/Mandat poste
VISA________________________________________exp___/_____

MasterCard__________________________________exp___/_____
Signature of credit card holder
Signature du titulaire de la carte
Phone/ Email (if different than above)
Téléphone/Corriel (s’il est different de
celui ci-dessus)
 Please contact me directly for payment details
If submitting registration electronically via acrobat.com, this form is encrypted. Your credit card
information will not be accessible by any third-parties.
If you would prefer to be contacted directly by the Lifesaving Society office for payment
information, please check above box.
2011 Canadian Lifeguard Emergency Respo nse Champio nship Registration
Page |3
2.
M
F
3.
M
F
4.
M
F
Name/Nom
Sex/
Sexe
Date of Birth
Date de
naissance
Y-M-D
A-M-J
Brown, John
M
F
83-05-20
2.
M
F
2.
M
F
3.
M
F
4.
M
F
Age
Age
LS ID Number
Barnsley Relay
Equipe de relais de Barnsley
(Exhibition)
M
F
Individual First Aid
individuelle de premiers soins
(Exhibition)
1.
LS ID Number
Priority Assessment
èvaluation Priorité
Individual First Aid
individuelle de premiers soins
(Exhibition)
Barnsley Relay
Equipe de relais de Barnsley
(Exhibition)
83-05-20
Priority Assessment
èvaluation Priorité
M
F
Age
Age
Water Rescue
Surveillance
Brown, John
Water Rescue
Surveillance
Sex/
Sexe
First Aid
Premiers soins
Name/Nom
Date of Birth
Date de
naissance
Y-M-D
A-M-J
First Aid
Premiers soins
TEAM A
Exhibition Event
28
BRJ520
√
√
√
√
√
TEAM B
Exhibition Event
28
BRJ520
√
√
√
√
√
2011 Canadian Lifeguard Emergency Respo nse Champio nship Registration
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2011 CANADIAN LIFEGUARD EMERGENCY RESPONSE CHAMPIONSHIP
WAIVER AND RELEASE
Please read carefully before signing
Each competitor must sign this form with the entry form to be eligible to compete. Participants 18 years and under must
have the form signed by their parent or guardian.
1. Conduct
I agree to abide by the rules, regulations, and code of conduct of the championship, and further to behave in a manner
consistent with good sportsmanship.
2. Voluntary Assumption of Risk
As a competitor in a lifeguard competition, I recognize that there are certain risks inherent in the activity as a result of
factors including but not limited to, stress, number of people, water temperature and conditions. I have prepared myself
for the competition and know of no factor or condition which should be disclosed to the organizers or which would
make it unsafe for me to compete. I voluntarily assume all risks, both physical and legal including but not restricted to
loss or damage to property, and personal injury including permanent disability or death.
3. Waiver of Liability
As a condition of entry and in consideration of my application as an individual or as part of a team being accepted, I hereby
waive my right to make any claim, whether for negligence or otherwise against the Lifesaving Society, the owner or occupier,
the sponsors, the organizing committee or any of the servants, agents, affiliates, volunteers, judges, officials, or other persons
involved in the organization of and the running of the competition, events or sanctioned associated activities. I further agree
to indemnify and hold harmless all of the above, from any claim made on my behalf or as a result of injury to my person or
property.
4. Model Release
I transfer to the Lifesaving Society all rights whatsoever which I have in photographs and/or videos that photographers
may have taken. I consent to the use of the photographs/videos and my name for all purposes whatsoever, including
without limitation, television, publications, and any trade or advertising purposes.
I have carefully read and understand the four conditions of entry and in consideration for being allowed to compete, I
have executed them voluntarily intending to be bound thereby and intending these conditions to be binding of my heirs,
personal representative and assigns.
Parent’s signature if minor
Name/Nom
Signature/Signature
Date/Date
Coach
Manager
Team Captain
2
3
4
5
6
7
8
Please use another page if needed.
2011 Canadian Lifeguard Emergency Respo nse Champio nship Registration
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CANADIEN DE SAUVETAGE D'INTERVENTION D'URGENCE CHAMPIONNAT
RENONCIATION ET LIBÉRATION
S'il vous plaît lire attentivement avant de signer
Chaque concurrent doit signer cette forme avec la fiche d'inscription pour avoir droit de rivaliser. Les participants 18 ans et sous
doivent faire signer la forme par leur parent ou gardien.
1. Conduite
J'accepte de respecter les règles, les règlements et le code de conduite du championnat et davantage me comporter dans une
manière en accord avec le bon esprit sportif.
2. Hypothèse Volontaire de Risque
Comme un concurrent à une compétition de gardien de plage, je reconnais qu'il y a de certains risques inhérents dans l'activité à la
suite des facteurs en incluant, mais non limité à, la tension, le nombre des gens, la température d'eau et les conditions. Je me suis
préparé à la compétition et ne sais d'aucun facteur ou de condition qui devrait être révélée aux organisateurs ou qui le rendrait
dangereux pour moi pour rivaliser. Je suppose volontairement tous les risques, inclusion tant physique que juridique, mais non
restreint à la perte ou au dommage à la propriété et à la blessure personnelle en incluant l'infirmité permanente ou la mort.
3. Renonciation à la Responsabilité
Comme une condition d'entrée et en considération de mon application comme un individu ou comme faisant partie d'une équipe
étant acceptée, je déroge par la présente à mon droit de faire n'importe quelle revendication, si pour la négligence ou autrement
contre la Société Lifesaving, le propriétaire ou l'occupant, les sponsors, le comité d'organisation ou n'importe lequel des
domestiques, les agents, les filiales, les volontaires, les juges, les fonctionnaires, ou d'autres personnes impliquaient dans
l'organisation d'et la course à pied de la compétition, les événements ou les activités associées autorisées. J'accepte davantage
d'indemniser et tenir pas méchant tous les susdits, de n'importe quelle revendication fait sur mon nom ou à la suite de la blessure à
ma personne ou propriété.
4. Libération Modèle
Je transfère à la Société Lifesaving tous les droits du tout que j'ai aux photographies et-ou les vidéos que les photographes peuvent
avoir prises. Je consens à l'utilisation des photographies/vidéos et de mon nom pour tous les buts du tout, en incluant sans
limitation, la télévision, les publications et n'importe quel commerce ou les buts de publicité.
J'ai soigneusement lu et comprends les quatre conditions d'entrée et dans la considération pour être permis de rivaliser, je les ai
exécutés en ayant volontairement l'intention d'être attaché ainsi et en destinant ces conditions de me lier de mes héritiers,
représentant personnel et alloue.
Nom
La signature de parent si le mineur.
Signature
Date
Directeur
D’entraîneur
Capitaine de
d’équipe
2
3
4
5
6
7
8
S.V.P. utiliser une autre page au besoin.
2011 Canadian Lifeguard Emergency Respo nse Champio nship Registration
Page |6

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