Castaic Lake
Junior Lifeguard Program
Application Packet Instructions
*Please read all Instructions before filling out Registration Packet. Please retain this page for further
reference.
SPACE IS LIMITED SO PAY FEES AND REGISTER EARLY TO ENSURE
YOUR ENROLLMENT.
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Junior Lifeguard Program Application Packet- Complete all items. PLEASE remember to sign and
date.
Authorization of Consent to Treatment of a Minor- All Physician and Insurance information must
be complete. Only (1) parent/guardian signature is needed on this form.
Press and Photo Release- Only (1) parent/guardian signature is needed on this form.
Physicians Release Form- Physician MUST complete form and form must have office stamp on
bottom of form.
Code of Conduct- Read and discuss with participant, then sign and return. Participant AND
parent/guardian must sign this form.
ALL the above must be submitted one week prior to the session start
date or the participant will be dropped from the program.
Submit forms and payment to:
Checks payable to Los Angeles County Parks & Recreation
Castaic Lake Recreation Area
Junior Lifeguard Program
32132 Castaic Lake Dr.
Castaic, Ca. 91384
DEADLINE for submitting forms and all payment of fees is June 1, 2015 for Session 1
NO PAYMENTS WILL BE ACCEPTED ON THE FIRST DAY OF THE PROGRAM
SPACE IS LIMITED.
All New Participants must pass the qualifying swim test in order to participate in the program. The
test consists of a 100 yard swim in 2:30, tread water for 3 minutes, and 10 yards under water.
*Checks, CC, or money orders only* Make checks payable to: Los Angeles County Department of Parks
and Recreation.
ALL transactions will be processed at the park headquarters or by phone.
-Please include Drivers License # and participants name on checks.
PROGRAM FEE-_$_______275___________
Refund Policy: If your child is unable to participate, a refund may be available ONLY if the child has
not participated in the session he/she is registered for. All refund requests must be submitted in writing
and will be evaluated on a case by case basis. PLEASE NOTE: The uniform cost ($125.00) is NONREFUNDABLE.
Registration is not FINAL until ALL forms, fees, and Releases are received. Applications will be
processed as they are received. If you are a NEW Applicant you may turn in your forms and fees to
reserve a spot on the Entry List, BUT a qualifying try-out must be taken and PASSED before you can
participate in the program. Returning Junior Lifeguards may turn in Applications and pay fees as well
to reserve a spot on the Entry List. All processed Applications are on a first come first served bases;
once the program is at capacity a waiting list will be generated. If you are participating in both
Sessions then the 2nd Session is $150.00 (BUT does not include a second uniform issue).
Financial Assistance is available to those who qualify. Forms may be obtained on our web site at
CastaicJgs.com and must be submitted before June 1st, 2015.
----------------------------------------------------------------------Pursuant to the Americans with Disabilities Act (ADA), the County of Los Angeles Department of Parks and
Recreation has designated an ADA Coordinator to carry out this Departments compliance with the nondiscriminatory provisions of the ADA. For more information you can contact the ADA Coordinator’s office: TEL:
213-738-2970 TDD: 213 427- 6118 FAX: 213 487-0380.
Upon 3-day request notice, sign-language interpreters and related materials in alternate formats (Braille-transcript,
large print, audio-record, video- captioning, and live description) or any other reasonable accommodations are
available to the public for County Sponsored activities and events.
EMAIL__________________________________________________________________
COUNTY OF LOS ANGELES
DEPARTMENT OF PARKS AND RECREATION
CASTAIC LAKE AREA
JUNIOR LIFEGUARD PROGRAM
(Please print clearly)
Childs Name__________________________________ Session (Please circle) 1
Circle One:
NEW JG
RETURNING JG
2 Both
_______ # yrs in program
Address__________________________________________________ City______________
State_________ Zip___________ Home # (
) _______________________
Birth Date_______/_______/________ Age ________ Gender
M
F
Short size_______ T-Shirt size_______ Swim suit (female) ______ Sweatshirt size________
Mother’s Name___________________________ Day time # (
____________________
)
Father’s Name____________________________ Day time # (
____________________
)
Guardian’s Name__________________________ Day time # (
___________________
)
In the event of an Emergency when the parent/guardian is unavailable, please provide
the name and number of a reliable friend or relative that may be contacted.
Emergency Contact Name____________________________ Phone (
________________
)
Liability Waiver: In consideration of my child being allowed to participate in the Los Angeles County Department of
Parks and Recreation Junior Lifeguard Program, I do hereby, for myself, my child, my heirs, and executors, waive release and
forever discharge any and all rights and claims for the damages which may, hereafter, accrue to me against the County of Los
Angeles and each of its officers, agents and employees for any and all injuries sustained out of my child’s association with, entry
in, participation on, or traveling to and from said Junior Lifeguard Program at Castaic Lake Recreation Area. I also understand
that any behavior deemed unacceptable by Instructors will result in participant being dropped from the program without a
refund. No minor will be permitted to attend the Junior Lifeguard Program at Castaic Lake without a signed and completed
Physicians Release Form.
Signed___________________________________________ Date_____________________________
The fee for the Program is $_________. PLEASE make checks payable to Los Angeles County
Department of Parks and Recreation. Also include your Drivers License # and the participants
name on all checks.
Method of payment:
*DO NOT SEND CASH* (check one)
Check#__________ VISA_________ MASTERCARD________ DISCOVER__________________
Card Holder Signature_______________________________________________________________
OFFICE USE ONLY
Amount Due $_____________ Amount Paid $_____________ Date
Paid _______________________
Check #____________ Check Name_____________________
VISA______________ MC______________ Cash _________
DISCOVER_____________ PR/LACARRS__________________
Drivers License________________________
County of Los Angeles
Department of Parks and Recreation
Junior Lifeguard Program
AUTHORIZATION OF CONSENT TO TREATMENT
OF A MINOR
I ( WE ) the undersigned, parent(s)/guardian(s) of ___________________________________, a minor,
do hereby authorize all representative’s of the Los Angeles County Department of Parks and
Recreation as agent(s) for the undersigned, to consent to any examination, X-ray, anesthetic, medical
or surgical diagnosis or treatment and hospital care that is deemed advisable by and rendered under
the general or special provision of any physician and surgeon licensed under the provisions of the
Medical Practice Act or the medical staff of any accredited hospital, but is given to provide authority
and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis,
treatment or hospital care which the aforementioned physician in the exercise of his best judgment
may deem advisable.
It is understood that effort shall be made to contact the undersigned prior to the rendering of
treatment to the patient, but that none of the above treatments shall be withheld if the undersigned
can not be reached.
This authorization shall remain effective through 2015 Junior Lifeguard Program Sessions, unless
sooner revoked in writing and delivered to said agent(s).
Parent’s Name (Please Print) _____________________________________________________________
Parent’s Signature__________________________________ Daytime Phone#_____________________
Guardian’s Name (Please Print) __________________________________________________________
Guardian’s Signature_______________________________ Daytime Phone#_____________________
Date_______________________
IN COMPLIANCE WITH CONSENT MANUAL, CALIFORNIA HOSPITAL ASSOCIATION.
Physicians Name____________________________________ Phone #___________________________
Insurance Carrier___________________________________ Policy #___________________________
Insured’s Name_____________________________________ Insured’s ID#______________________
MEDICAL INFORMATION: Please include known allergies, allergic reactions, special medications,
medical problems/conditions. If none exist, please note NONE in the space below.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
*THE ABOVE MUST BE FILLED OUT COMPLETELY AND SIGNED FOR YOUR CHILD TO
REGISTER AND PARTICIPATE IN THE JUNIOR LIFEGUARD PROGRAM.
COUNTY OF LOS ANGELES
DEPARTMENT OF PARKS AND RECREATION
JUNIOR LIFEGUARD PROGRAM 2015
CASTAIC LAKE
CODE OF CONDUCT
Youth participating in or attending the County of Los Angeles, Department of Parks and
Recreation, Castaic Lake Junior Lifeguard Program are required to conduct themselves
according to the “Code of Conduct” that follows this introduction. The Code operates in
conjunction with the guidelines and regulations of the specific event show, program,
and/or activity.
Program Participant Expectations:
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Participate fully in the program, activity and/or event.
Be responsible for your own behavior/conduct, uphold high standards for the
group and accept the consequences for inappropriate behavior.
Support and abide by the program’s designated Instructors/Coordinator/Director.
Practice good citizenship, leadership and self-governance.
Follow the direction of the staff.
Demonstrate positive sportsmanship and attitudes at all times that is becoming of
a leader.
Show respect to others by being courteous and respectful.
Use appropriate language at all times.
Respect and adhere to the guidelines of the program.
Behavior, Conduct or Activity Not Permitted:
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Unsportsmanlike, unethical, immoral conduct.
Improper language(i.e.-profanity)
Possession or consumption of alcohol.
Possession or use of illegal drugs, including the use of tobacco.
Possession or use of weapons, fireworks.
Possession or use of harmful objects with the intent to harm or intimidate others.
Destruction of County property (i.e. - graffiti, program equipment, etc.)
Violation of established program start and end times for drop offs and pick ups.
Disrespect for adults, other participants, volunteers, staff and/or those who are in
a leadership position.
Belittling others; putting others down and being disrespectful of individual
differences.
Aggressive, physical behavior (i.e. - fighting).
Taking property that belongs to others, stealing; borrowing/using others’ property
without permission of the owner.
Other conduct determined to be inappropriate by the Program Director,
Coordinator, Instructor’s and facility Management/Staff.
Actions taken when in violation of the “Code of Conduct.”
1. The parent/guardian of the participant(s) involved in the
violation will be notified or made aware of the violation and
appropriate action will be taken by the Program staff or Director.
2. The participant(s) can/may be barred from participating in
program activities for the remainder of that week or even the
remainder of the program session depending on the circumstance/violation.
3. Should a violation(s) warrant an expulsion from the program for that season or
indefinitely, it shall be so with NO refund of the program fees.
4. When warranted, the situation may be turned over to the proper law enforcement
authorities.
JUNIOR LIFEGUARD PROGRAM CODE OF CONDUCT AGREEMENT
I, ___________________________________, as a participant of the County of Los
(Print Program Participant)
Angeles, the Department of Parks and Recreation, Castaic Lake Junior Lifeguard
Program have read the “Code of Conduct”, and agree and abide by it. I also accept the
consequences for my actions, if I choose not to follow the code.
_____________________________________________ Date______________________
(Participant Signature)
I/We________________________________________________________ have read the
“Code of Conduct” and agree and support my child’s participation in the programs
activities and events.
_____________________________________________ Date______________________
(Parent/Legal Guardian Signature)
PHYSICIAN’S RELEASE FORM
Name of Participant:_______________________________________________________
Address of Participant:___________________________________ City:______________
State:__________ Zip Code:_____________ Home Phone:________________________
TO THE PHYSICIAN:
The person you are examining is a participant actively engaged in the Junior Lifeguard
Program for the County of Los Angeles Department of Parks and Recreation. As such,
this person will be participating in physically demanding activities in a lake setting.
Activities will include, but not limited to, swimming, running, boating, calisthenics, and
prolonged exposure to sun and heat.
EXAMINATION RESULTS:
The participant named above is: (Circle one) ABLE
in the Junior Lifeguard Program.
NOT ABLE to participate
PARTICIPANT’S CONDITION: (Check one):_____Excellent_____Good_____Fair
GENDER:
M
F
Age:_________Height________Weight________
Pulse:___________B/P:_____________Temperature:________
RESTRICTIONS (If any):_________________________________________________
________________________________________________________________________
RECOMMENDATIONS (If any):___________________________________________
________________________________________________________________________
_____________________________________
__________________
SIGNATURE OF EXAMINING PHYSICIAN
OFFICE STAMP:
(Must be stamped)
COUNTY OF LOS ANGELES
DEPARTMENT OF PARKS AND RECREATION
JUNIOR LIFEGUARD PROGRAM 2015
CASTAIC LAKE
DATE
PRESS AND PHOTO RELEASE
I understand that my child may be photographed while participating
in the Los Angeles County Department of Parks and Recreation Junior
Lifeguard Program. I agree to allow these photos to be used for
promotional purposes without any monetary compensation and I
understand that these photos will be the property of Los Angeles
County. I also understand that my child may be photographed and/or
interviewed by the press while participating in the Los Angeles
County Department of Parks and Recreation Junior Lifeguard
Program.
Only one signature is required.
Applicants Name (please print):
Parent or Guardian’s Name (please print):
__________________________________________________
Parent or Guardian’s Signature:
__________________________________________________
Date: _____________
2015 CASTAIC LAKE JUNIOR LIFEGUARD PROGRAM