| Name: | ______________________________________ |
| Address: | ______________________________________ |
| ______________________________________ | |
| Day Phone: | ______________________________________ |
| Evening Phone: | ______________________________________ |
| E-mail Address: | ______________________________________ |
I certify that the above named person has passed
the following swimming ability requirements in my presence:
1. Swim a distance of 75 feet.
2. Tread water for five minutes.
3. Swim under water for a distance of 20 feet.
______________________________________ Date:_________________
WSI or Equivalent Signature
Pool:_________________
______________________________________
Red Cross Chapter
______________________________________
WSI or Equivalent Expiration Date
Last modified: May 02 2007 07:01:02 am:
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