Newfoundland & Labrador Branch

RECOMMENDATION FOR

RESCUE COMMENDATION CERTIFICATE

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RESCUER

Name:_________________________________________________Age:_____________

Telephone: Home:_____________________Work:______________________

Does the rescuer hold any Royal Lifesaving Society awards? Yes No

VICTIM(S)

Name:_______________________________________________Age:_______________

Address:
___________________________________________________________________________

Telephone: Home:_____________________Work:______________________

(If more than one rescuer/victim, please attached their names, etc. on a separate sheet of paper)
 
 
 
 

DETAILS OF RESCUE

Date of Rescue:_____________________________Time of Day:___________________

Location of Incident:_______________________________________________________

Weather Conditions:_______________________________________________________

Water Conditions:_________________________________________________________
 
 
 
 
 
 

Description of Rescue: (Please include specific details, with techniques and procedures used where applicable)
 
 
 
 
 
 
 
 
 
 

(Continue the description on a separate sheet, if necessary. Also attach signed statements from the victim(s) and/or witness(es), if applicable.)

Witness(es)

Name:___________________________________Telephone #:_____________________

Name:___________________________________Telephone #:_____________________

Name:___________________________________Telephone #:_____________________

Submitted by:

Name:______________________________________________Age:________________

Address:________________________________________________________________
 
 

Telephone #: Home:___________________Work:________________________

Date:__________________________Signature:_________________________________

Date:_______________________Rescuer’s Signature:____________________________

(if possible)
 
 
 
 
 
 

Please submit to: