USA SWIMMING 2009 ATHLETE REGISTRATION APPLICATION

REG. DATE / OFFICE USE ONLY LSC: MICHIGAN SWIMMING, INC.

PLEASE PRINT LEGIBLY l COMPLETE ALL INFORMATION:

LAST NAME LEGAL FIRST NAME MIDDLE NAME

PREFERRED NAME DATE OF BIRTH (MO./DAY/YR.) SEX (M/F) AGE CLUB CODE NAME OF CLUB YOU REPRESENT

IF UNATTACHED ENTER UN

FATHER/GUARDIAN LAST NAME FATHER/GUARDIAN FIRST NAME MOTHER/GUARDIAN LAST NAME MOTHER/GUARDIAN FIRST NAME

MAILING ADDRESS

–

CITY STATE ZIP CODE

AREA CODE TELEPHONE NO. U.S. CITIZEN? YES NO

MAKE CHECK PAYABLE TO:

ARE YOU A MEMBER OF ANOTHER FINA

FEDERATION? YES NO

MICHIGAN SWIMMING, INC.

DISABILITY: RACE AND ETHNICITY (You may

A. Legally Blind or Visually Impaired make up to two choices if appropriate): IF YES, WHICH FEDERATION:

MAIL APPLICATION & PAYMENT TO:

B. Deaf or Hard of Hearing Q. Black or African American

MICHIGAN SWIMMING OFFICE

PO BOX 1784

MIDLAND, MI 48641-1784

Email: jbcartmill@hughes.net

231-690-5847

C. Physical Disability such as R. Asian

REGISTRATION FEE

USA Swimming Fee $45.00

LSC Fee $8.00

TOTAL DUE $53.00

amputation, cerebral palsy, S. White

dwarfism, spinal injury, T. Hispanic or Latino

mobility impairment U. American Indian & Alaska Native

D. Cognitive Disability such as V. Some Other Race

mental retardation, severe W. Native Hawaiian & Other Pacific

learning disorder, autism Islander

YEAR LAST REGISTERED: . IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2008, ENTER THAT

CLUB CODE: LSC CODE: AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB: .

USA Swimming occasionally makes its membership list available to its

marketing partners. Please notify USA Swimming’s Member Services

Dept. at 719/866-4578 if you do not wish to receive these mailings.

SIGN

HERE x_____________________________________________________________________ CHECK IF YOU WOULD LIKE TO LEARN MORE ABOUT

SIGNATURE OF ATHLETE, PARENT OR GUARDIAN USA SWIMMING’S COMMUNITY INITIATIVES