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Summer Employment Application - Lifeguard (Beach)

First Name*
Middle Name
Last Name*
Address1*
Address2
City*
State*
Zip*
Home Phone Number*
Email Address*
Cell Phone Number*
Dates available to work: Start Month/Day to End Month/Day *
ARE YOU A RESIDENT OF THE TOWN OF SMITHTOWN? *
WILL YOU BE 16 YEARS OLD ON OR BEFORE DECEMBER 31? *
(Please note: If hired and under the age of 18, you must provide the age appropriate working papers to be in compliance with NYS Labor Laws. Working papers may be obtained at your high school from your guidance counselor.)
HAVE YOU PREVIOUSLY WORKED FOR THE TOWN OF SMITHTOWN? *
IF YES, PLEASE EXPLAIN:
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LIST THE HIGHEST HIGH SCHOOL GRADE LEVEL COMPLETED:
1. 9TH
2. 10TH
1. 11TH
2. 12TH
ENTER NAME OF HIGH SCHOOL:
IF YOU ARE A HIGH SCHOOL GRADUATE, ENTER NAME OF SCHOOL AND DATE OF GRADUATION:
IF YOU ARE IN COLLEGE,CHOOSE THE HIGHEST COLLEGE LEVEL COMPLETED:
ENTER NAME OF SCHOOL & MAJOR:
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APPLICANT MUST OBTAIN PROPER CERTIFICATIONS PRIOR TO EMPLOYMENT
(Must be 16 years of age at time of assignment)
Please choose from the list below as to what certifications you have and be sure to provide the expiration date(s). You may select more than one option as applicable.
Red Cross First/Aid Safety Certification
1. Yes
Expiration Date:
Expiration Date:
Red Cross CPR/Lifesaving Certification
1. Yes
Expiration Date:
Expiration Date:
Red Cross Lifeguard Training Certification
1. Yes
Expiration Date:
Expiration Date:
Red Cross Waterfront Module
1. Yes
Expiration Date:
Expiration Date:
American Red Cross Water Safety Instructor (WSI)
1. Yes
Expiration Date:
Expiration Date:
Describe the following areas that you have supervised or instructed. In your description, please indicate years of experience, honors or awards, and any pertinent information that would help describe your ability.
Lifeguarding Experience:
Competitive Swimming:
Coaching of Swimming, Diving, etc.:
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I certify that my answers are true and complete to the best of my knowledge and that intentional misrepresentations or omissions may be cause for the rejection of my application and that if hired I may be released from employment.

Your electronic signature below indicates your agreement with the following statement: By typing my name in the following box and clicking submit button I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing my employment application and information.
Applicant Signature*

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