Phone: 703.764.2744
Mailing Address: PO Box 2268, Springfield, Virginia 22152
Location: 9100 Burnetta Drive, Annandale, Virginia 22003
Due April 30
Lifeguard Application
Long Branch Swim & Racquet Club
Background Information
Name ______________________________________ Soc. Sec# ______________________________
Address __________________________________________________________________________
Home Phone # __________________ Cell Phone #_______________________
Email ______________________________________________
Birth date ___________________ US Citizen Yes/No
Fulltime Student Yes/No School Name and Grade ____________________________________
Employment Interest
Interested in Full time/Part time Dates Available Start _______ End _____
Average number of hours you want each week _________ Salary Desired ($/hr) ____________
Are you a member of this pool? Yes/No Are you on a swim team? Yes/No
Do you have any food/medical allergies? Yes/No If yes, please list __________________________
Events that you know will impact your ability to work (vacation, camp, school events, etc.)
Event Dates Time of Day Unavailable (afternoon/evening)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Lifeguard Experience
Years of lifeguard experience _______
Current Certifications
Type Date Received Expiration Date
Lifeguard ______________ _________________
First Aid ______________ _________________
CPR ______________ _________________
Pool Operator ______________ _________________
Work Experience
Employer _________________________ Position ______________ Dates Worked ______________
Supervisor/Phone Number __________________________________ Reason for leaving __________
Employer _________________________Position _______________ Dates Worked _____________
Supervisor/Phone Number __________________________________ Reason for leaving __________
References
Name Phone # Relationship
________________________ ___________________ ______________
________________________ ___________________ ______________
________________________ ___________________ _______________
Please provide any other information you would like for us to know on the backside of this
application. Any questions please contact Susan Hacker at 703 503-7887 or email at
irickhacker2@aol.com. Return application to 4907 Loosestrife Ct. Annandale, VA 22003