Download USA SWIMMING 2017 ATHLETE REGISTRATION APPLICATION

USA SWIMMING
2017 ATHLETE REGISTRATION APPLICATION
LSC: CT
PLEASE PRINT LEGIBLY COMPLETE ALL INFORMATION:
LAST NAME:_____________________________________________________
LEGAL FIRST NAME:______________________________________________ MIDDLE NAME :_________________________________________
DATE OF BIRTH (MO./DAY/YR.):_______________________________________________ SEX (M/F): ____________________
CLUB CODE:
PAC
CLUB YOU REPRESENT:
AGE: ______________________
PANTHER AQUATIC CLUB
FATHER/GUARDIAN LAST NAME: __________________________________ FATHER/GUARDIAN FIRST NAME:_________________________
MOTHER/GUARDIAN LAST NAME:__________________________________ MOTHER/GUARDIAN FIRST NAME:_________________________
MAILING ADDRESS:_______________________________________________________________________________________________________
CITY STATE ZIP CODE:____________________________________________ TELEPHONE NO:_________________________________________
FAMILY/HOUSEHOLD E-MAIL ADDRESS:____________________________________________________
ARE YOU A MEMBER OF ANOTHER FINA FEDERATION?
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
mental retardation, severe
learning disorder, autism
YES
RACE AND ETHNICITY (You may
make up to two choices if appropriate):
Q. Black or African American
R. Asian
S. White
T. Hispanic or Latino
U. American Indian & Alaska Native
V. Some Other Race
W. Native Hawaiian & Other Pacific
Islander
NO
U.S. CITIZEN? YES
NO
IF YES, WHICH FEDERATION?_____________________
APPLICATION/PAYMENT TO:
PANTHER AQUATIC CLUB (PAC)
c/o 1026 KETTLETOWN RD
SOUTHBURY, CT 06488
REGISTRATION FEE
USA Swimming Fee $56.00
LSC Fee $16.00
_
TOTAL DUE $72.00
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
Check if you would like to learn more about USA Swimming’s community
initiatives.
Check if you would like to receive the electronic USA Swimming
YEAR LAST REGISTERED_____________ . IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2013, PLEASE ENTER THAT CLUB CODE _______________,
LSC CODE _______________, AND THE DATE OF YOUR LAST SWIM COMPETITION REPRESENTING THAT CLUB _______________.
.
SIGN
HERE x ____________________________________________________________________________________________________
SIGNATURE OF ATHLETE, PARENT OR GUARDIAN