ࡱ> IKH#` bjbjmm 4$ \ \ \ \ x  ^``````$h  GGG "  ^G ^GG \t@\ ^0,P 2 hG T    \ \   2010 USMS Membership Registration New_____ Renewal____(past USMS #____________) Register with the same name you will use for competition. PLEASE PRINT CLEARLY. Last Name:_______________________ First Name:__________________ MI:______ Street Address:_________________________________________ Phone:___________________ City/State/Zip:__________________________________________________ Date of Birth:______________ Email Address:______________________________________ Sex: (circle) M F (Email addresses ARE NOT supplied to sponsors) Team Name/Unattached:_______________________________________________________ WAIVER: I the undersigned participant, intending to be legally bound, hereby certify that I am physically fit and have not been otherwise informed by a physician. I acknowledge that I am aware of all the risks inherent in Masters swimming (training and competition) including possible permanent disability or death, and agree to assume all of those risks. AS A CONDITION OF MY PARTICIPATION IN THE MASTERS SWIMMING PROGRAM OR ANY ACTIVITIES INCIDENT THERETO, I HEREBY WAVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES, INCLUDING ALL CLAIMS FOR DAMAGES CAUSED BY THE NEGLIGENCE, ACTIVE OR PASSIVE, OF THE FOLLOWING: UNITED STATES MASTERS SWIMMING, INC., THE LOCAL MASTERS SWIMMING COMMITTEES, THE CLUBS, HOST FACILITIES, MEET SPONSORS, MEET COMMITTEES, OR ANY INDIVIDUALS OFFICIATING AT THE MEETS OR SUPERVISING SUCH ACTIVITIES. In addition, I agree to abide by and be governed by the rules of USMS. Signature (required)____________________________________________________ Use of Image/Likeness: I grant permission to U.S. Masters Swimming and its affiliates to use my likeness and/or image in photographs, video, motion pictures, recording, or any other record for legitimate purpose. __I am a coach ___Certified Official I am a member of ___YMCA ___USA Triathlon ___USA Swimming Fees: USMS fee $27.00 ___ ***18-24 year olds: USMS fee $20.00 ___ (All registrations valid through 12/31/10) LMSC fee $ 8.00 ___ LMSC fee $0.00 ____ VMST fee $15.00____ VMST fee $15.00____ ___I wish to contribute $1.00 (or $____) to the International Swimming Hall of Fame Foundation. I have added this to my total fees. ___I wish to contribute $1.00 (or $____) to the United States Masters Swimming Foundation. I have added this to my total fees: TOTAL FEE:___________ NOTE: If joining from 9/1/10 through 10/31/10, with the exception of 18-24 year olds, fees are reduced by $8.00. *** 18-24 year olds MUST REGISTER PRIOR TO YOUR 25TH BIRTHDAY! MAKE CHECK PAYABLE TO: LMSC FOR VIRGINIA Mail this form and check to: Lisa Bennett, Registrar swimlab56@msn.com 11812 Winfore Drive (804) 379-5324 Midlothian, VA 23113 USMS Registered members are covered with secondary accident insurance: in practices supervised by a USMS member or USA Swimming certified coach where all swimmers are USMS registered. 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