Intention form

Please fill in below

Firstname *

Lastname *

Email *

Birthday

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day Day12345678910111213141516171819202122232425262728293031

Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024

Administrative region * Abitibi-TémiscamingueBas-Saint-LaurentCapitale-NationaleCentre-du-QuébecChaudière-AppalachesCôte-NordEstrieGaspésie-Îles-de-la-MadeleineLanaudièreLaurentidesLavalMauricieMontérégieMontréalNord-du-QuébecOutaouaisSaguenay/Lac-Saint-Jean

Selected certification * - Select -Aquatic Emergency CareBoat RescueBoat Rescue For First RespondersBronze CrossBronze MedallionBronze StarCardiopulmonary Resuscitation - ACardiopulmonary Resuscitation - BCardiopulmonary Resuscitation - CCPR - Healthcare ProviderEmergency First AidEmergency First Aid - Early Childhood - 8HEmergency First Aid - Sport and RecreativeEmergency First Aid/AEDFirst Aid Instructor - 16 HoursFirst Aid Instructor - 32 HoursIce Rescue With BoatIce Rescue Without BoatLifesaving InstructorNational Lifeguard - PoolNational Lifeguard - SurfNational Lifeguard - WaterfrontNational Lifeguard - WaterparkPleasure Craft Operator CardPleasure Craft Operator InstructorPool AttendantPrevention Waterfront AreasRecertification - Aquatic Emergency CareRecertification - Bronze CrossRecertification - Bronze MedallionRecertification - First Aid InstructorRecertification - Lifesaving InstructorRecertification - National Lifeguard - PoolRecertification - National Lifeguard - SurfRecertification - National Lifeguard - WaterfrontRecertification - National Lifeguard - WaterparkRecertification - Standard First AidResponder in Waterfront AreasStandard First AidStandard First Aid - Sport and recreativeSwim InstructorSwim Instructor RecertTrainer - Lifesaving InstructorWater Quality

Desired date

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day Day12345678910111213141516171819202122232425262728293031

Year Year2023202420252026

I agree to have my contact information transmitted to an organisation that is affiliated to the Lifesaving Society and that offers the course to which I want to register or about which I want more information. *

I accept

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