Kennebec Valley YMCA Stingrays: Home
..
_----_._-------------------------------------------,
USA SWIMMING CHECK
APPROPRIATE
o SEASON
1
SEASONAL
0 SEASON
2017 SEASONAL ATHLETE REGISTRATION APPLICATION LSC: MAINE SWIMMING, INC.
PERIOD:
THIS MEMBERSHIP ZONE, SECTIONAL
2
PLEASE PRINT LEGIBLY.
LEGAL
[
FIRST NAME
MIDDLE
-----'11"-------
P_R_EF_E_R_R_E_D_N_A_M_E
(Bill, Beth, Scooter, GUARDIAN
II
1
DAITE 0 BI~TH
Liz, Bobby) #1 LAST NAME
GUARDIAN
____
11'---SEX
1MW
I
0
1MWr
K~~~::
I_Ck,-L-=-U_~_C--,~_DE--,11
11 MAILING
~F
v:
C
-
l\:U
STATE
_______
IDI FAMIL Y/HOUSEHOLD
NO.
-
ZIP CODE
E-MAIL
_
DYES
0 NO
ARE YOU A MEMBER OF ANOTHER FEDERATION? DYES D NO
ADDRESS
IF YES, WHICH
FINA
FEDERATION:
II
II
OPTIONAL DISABILITY: A. Legally Blind or Visually Impaired B. Deaf or Hard of Hearing C. Physical Disability such as amputation. cerebral palsy, dwarfism, spinal injury, mobility impairment D. Cognitive Disability such as severe learning disorder, autism
o o o o
YEAR LAST REGISTERED: LSC CODE:
HAVE YOU REPRESENTED THAT FEDERATION AT INTERNATIONAL COMPETITION? DYES D NO
MAKE CHECK PAYABCE'TO;";
RACE AND ETHNICITY (You may check up to Iwo choices): Q. Black or African American DR Asian OS. White 1. Hispanic or Latino U. American Indian & Alaska Native V. Some Other Race W. Native Hawaiian & Other Pacific Islander
o
~ MAIL APPLICATION
KVYI4CA & PAYMENfiPtl;
2017 REGISTRATION
o o o o
HIGH SCHOOL STUDENTS - Year of high school graduation:
USA Swimming Fee LSC Fee
TOTAL DUE
o
_
. IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2016, ENTER THAT AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB:
_
o
~~~~~~~~~~~~~~~~~~---SIGNATURE OF ATHLETE,
PARENT
OR GUARDIAN
DATE
FEE $30.00 $8.50
$38.50
Check if you would like to learn more abcut the USA Swimming Foundation's initiatives Check if you would like to receive the electronic USA Swimming Newsletter (must be 13 years of age or older)
SIGN HEREx
#2 FIRST NAME
11
U.S. CITIZEN:
TELEPHONE
REPY~~A
ADDRESS
CITY
AREA CODE
NAME
If not affiliated with a club, enter "Unattach~' GUARDIAN #2 LAST NAME GUARDIAN
#1 FIRST NAME
11
CLUB CODE:
LEVELS.
COMPLETE ALL INFORMATION:
LAST NAME
I
IS ONL Y FOR MEETS BELOW AND NATIONAL
REG. DATE/LSC
USE ONLY
_----_._-------------------------------------------,
USA SWIMMING CHECK
APPROPRIATE
o SEASON
1
SEASONAL
0 SEASON
2017 SEASONAL ATHLETE REGISTRATION APPLICATION LSC: MAINE SWIMMING, INC.
PERIOD:
THIS MEMBERSHIP ZONE, SECTIONAL
2
PLEASE PRINT LEGIBLY.
LEGAL
[
FIRST NAME
MIDDLE
-----'11"-------
P_R_EF_E_R_R_E_D_N_A_M_E
(Bill, Beth, Scooter, GUARDIAN
II
1
DAITE 0 BI~TH
Liz, Bobby) #1 LAST NAME
GUARDIAN
____
11'---SEX
1MW
I
0
1MWr
K~~~::
I_Ck,-L-=-U_~_C--,~_DE--,11
11 MAILING
~F
v:
C
-
l\:U
STATE
_______
IDI FAMIL Y/HOUSEHOLD
NO.
-
ZIP CODE
_
DYES
0 NO
ARE YOU A MEMBER OF ANOTHER FEDERATION? DYES D NO
ADDRESS
IF YES, WHICH
FINA
FEDERATION:
II
II
OPTIONAL DISABILITY: A. Legally Blind or Visually Impaired B. Deaf or Hard of Hearing C. Physical Disability such as amputation. cerebral palsy, dwarfism, spinal injury, mobility impairment D. Cognitive Disability such as severe learning disorder, autism
o o o o
YEAR LAST REGISTERED: LSC CODE:
HAVE YOU REPRESENTED THAT FEDERATION AT INTERNATIONAL COMPETITION? DYES D NO
MAKE CHECK PAYABCE'TO;";
RACE AND ETHNICITY (You may check up to Iwo choices): Q. Black or African American DR Asian OS. White 1. Hispanic or Latino U. American Indian & Alaska Native V. Some Other Race W. Native Hawaiian & Other Pacific Islander
o
~ MAIL APPLICATION
KVYI4CA & PAYMENfiPtl;
2017 REGISTRATION
o o o o
HIGH SCHOOL STUDENTS - Year of high school graduation:
USA Swimming Fee LSC Fee
TOTAL DUE
o
_
. IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2016, ENTER THAT AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB:
_
o
~~~~~~~~~~~~~~~~~~---SIGNATURE OF ATHLETE,
PARENT
OR GUARDIAN
DATE
FEE $30.00 $8.50
$38.50
Check if you would like to learn more abcut the USA Swimming Foundation's initiatives Check if you would like to receive the electronic USA Swimming Newsletter (must be 13 years of age or older)
SIGN HEREx
#2 FIRST NAME
11
U.S. CITIZEN:
TELEPHONE
REPY~~A
ADDRESS
CITY
AREA CODE
NAME
If not affiliated with a club, enter "Unattach~' GUARDIAN #2 LAST NAME GUARDIAN
#1 FIRST NAME
11
CLUB CODE:
LEVELS.
COMPLETE ALL INFORMATION:
LAST NAME
I
IS ONL Y FOR MEETS BELOW AND NATIONAL
REG. DATE/LSC
USE ONLY
