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REHOBOTH BEACH PATROL
CITY OF REHOBOTH BEACH, DELAWARE
APPLICATION FOR EMPLOYMENT
SURF-LIFEGUARD PRE-EMPLOYMENT TEST

Name_________________________________________________________________
   (please print)      Last                             First                             MI

Address_______________________________________________________________
                          Number                                 Street

______________________________________________________________________
                             City                                      State                                Zip

Phone#________________________ Email___________________________________


Age                Birth Date           /          /          Birthplace ____________________________
                                        Month  Day   Year

Surf lifeguard Experience ________________________________________________
                                             (Please list by year all seasons worked)

I can work full time starting         /         /              and ending          /         /       
                                          Month   Day    Year                        Month   Day   Year

In consideration of granting this application, I herby for myself (my child/my ward), my (his/her) heirs, executors, and administrators, waive and release any and all rights and claims for damage I (my child/my ward) may have against the Rehoboth Beach Patrol and/or the City of Rehoboth Beach, their agents, representatives, assigns, for any and all injuries suffered by me (my child/my ward) while participating in the Surf-Lifeguard Pre-employment Test conducted for and by the Rehoboth Beach Patrol and the City of Rehoboth Beach.

_____________________________                      _____________________________     
Signature of approval of parent                               Signature of Applicant
Or guardian for child or ward
Under 18 years of age.

Delivery Options:
Mail to: City of Rehoboth Beach, 229 Rehoboth Avenue, De 19971
Fax to: (302) 227-4643 Attention: Captain Buckson
Bring to: Pre-Employment Test

--------------------------NOT TO BE FILLED OUT BY APPLICANT-------------------------
Statement of Examining Physician (Optional)

This is to certify that I have reviewed the content of the Surf-Lifeguard Pre-employment Test and find the above applicant health enough to participate in said test at this time without danger to himself/herself.

Name ____________________________     M.D. License______________________
          Name of Examining Physician                                  State   Number

Office____________________________      Telephone  (             )________________
                Town     State       Zip                                   Area Code        Number

Signature________________________        Date             /       /          
                    Signature of Physician                   Month    Day   Year                    Back