FL LMSC Individual Interactive Registration Form

2013 Florida LMSC / USMS Membership Registration

Instructions: Type it -- Print it -- Sign it -- Mail it.

Information in red shaded areas is optional.

P E R S O N A L . I N F O R M A T I O N . (Use the SAME NAME you will use for competition)

LAST name

FIRST name
MI

address

city, state zip

phone
w\area code
.hw
email

date of birth
// age
sex
.M F

I have changed my address within the last year

I am a Masters coach I am a certified official

Send the Florida LMSC Newsletter by postal mail, by email, or don't send

R E G I S T R A T I O N . I N F O R M A T I O N

Select ONE club from one of the pop-up menus below, and add the club registration fee at the bottom if applicable

FACT

I am currently a USMS member and my USMS number is

L I A B I L I T Y . R E L E A S E

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 WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES, INCLUDING ALL CLAIMS FOR LOSS OR 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 and regulations of USMS.

signature required: ____________________________________________ date//

R E G I S T R A T I O N . F E E S (membership effective Nov. 1, 2012-Dec. 31, 2013)

(red area optional; white/green areas required)
.I wish to contribute $1 (or $) to the International Swimming Hall of Fame Foundation

.total from right
$
.I wish to contribute $1 (or $) to the USMS "Swimming Saves Lives Fund"

USMS/LMSC fee
$.....41.00

If registering between 9/1/13-10/31/13, deduct $5 from fee, but membership effective only until 12/31/13

MEMBERSHIP BENEFITS: A subscription to USMS Swimmer during the length of the membership year ($8 of the annual dues is designated for a USMS Swimmer subscription, and periodic mailings from the Florida Local Masters Swimming Committee. USMS-registered swimmers are covered with secondary accident insurance (1) in practices supervised by a USMS member or a USA-certified coach where all swimmers are registered, and (2) in USMS-sanctioned meets where all competitors are USMS-registered.

FACT registration if applicable ($7)
$

Club registration from above, if applicable
$

TOTAL
$

Payment information or enter contact information below:

	2013 Florida LMSC / USMS Membership Registration
	Instructions: Type it -- Print it -- Sign it -- Mail it.
	Information in red shaded areas is optional.

P E R S O N A L . I N F O R M A T I O N . (Use the SAME NAME you will use for competition)
LAST name		FIRST name	MI
address		city, state zip
phone w\area code	.hw	email
date of birth	// age	sex	.M F
I have changed my address within the last year		I am a Masters coach I am a certified official
Send the Florida LMSC Newsletter by postal mail, by email, or don't send
R E G I S T R A T I O N . I N F O R M A T I O N
Select ONE club from one of the pop-up menus below, and add the club registration fee at the bottom if applicable

FACT		I am currently a USMS member and my USMS number is
L I A B I L I T Y . R E L E A S E
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 WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES, INCLUDING ALL CLAIMS FOR LOSS OR 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 and regulations of USMS.
*signature required:* ____________________________________________ date//

R E G I S T R A T I O N . F E E S (membership effective Nov. 1, 2012-Dec. 31, 2013)
(red area optional; white/green areas required)		.I wish to contribute $1 (or $) to the International Swimming Hall of Fame Foundation
.total from right	$	.I wish to contribute $1 (or $) to the USMS "Swimming Saves Lives Fund"
USMS/LMSC fee	$.....41.00	If registering between 9/1/13-10/31/13, deduct $5 from fee, but membership effective only until 12/31/13 MEMBERSHIP BENEFITS: A subscription to USMS Swimmer during the length of the membership year ($8 of the annual dues is designated for a USMS Swimmer subscription, and periodic mailings from the Florida Local Masters Swimming Committee. USMS-registered swimmers are covered with secondary accident insurance (1) in practices supervised by a USMS member or a USA-certified coach where all swimmers are registered, and (2) in USMS-sanctioned meets where all competitors are USMS-registered.
FACT registration if applicable ($7)	$
Club registration from above, if applicable	$
TOTAL	$