LIFEGUARD COURSE REGISTRATION

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Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Cell Phone
Home Phone
E-mail
Emergency Contact
Emergency Phone
Medical Conditions

Please provide: All participants Must be at least 15 years of age by the end of the course.

Date of Birth

Choose one of the following options: 

 Payment of $195.00 is due to Douglas Aquatics seven(7) days before the start of the course.  Please mail a check to our office at 1900 E. Belt Blvd, Richmond, VA 23224 or call us at 804-232-0225 to pay with credit card via the phone.

Thanks for your registration. We look forward to seeing you in class!