Member of USA Swimming

Transcription

1 Registration Form Apr 2016-Aug 2016 Member of USA Swimming Birth Certificate: If this is your first time joining a USA Swimming team, you must provide a copy of the athlete s birth certificate. Swimmer s Last Name Today s Parents Names Parent 1 Parent 2 Address Home Phone Number City & Zip Work/Cell Phone(s) Address(es) Group Name Monthly Tuition Practice times Elite $135 M/W/F 6:30-8 pm & T/Th 6-8 pm + offsite dry-land, times vary Senior $110 M/W/F 5-6:30 pm & T/Th 5-6 pm Junior 3 $85 M/W/F 4-5 pm or 5-6 pm Junior 2 $70 T/Th 4-5 pm or 5-6 pm Junior 1 $40 T/Th 3:30-4 pm Swimmer #1 Swimmer #2 First Name & Middle Initial: of Birth: Swim Group: Days/Times: Monthly Tuition: USA Swimming Membership Fee: $50 $50 TEAM Registration Fee: $30 $30 Total Due: PLEASE MAKE CHECKS PAYABLE TO LSAC" (Lone Star Aquatic Club) Monthly fees are due by the first of each month. A late charge will be applied to delinquent accounts. Training fees are due each month to maintain your position on the team. All fees are non-refundable.

2 Financial Agreement & Photo Release Lone Star Aquatic Club (LSAC) is a non-profit organization working hard to provide an outstanding, stable, and financially sound competitive swimming program for swimmers of all ages and abilities. LSAC reserves the right to adjust practice times to meet the overall needs of the program. All fees are non-refundable. Fees include: Annual USA Swimming membership fee Annual team registration fee Monthly tuition/training fees Swim Meet fees, if participating Annual fundraising fee of $25, if a fundraiser is needed The team trains 12 months each year. Training fees are due at the beginning of each month to maintain your swimmer s position on the team. If you want to drop from the team, notify the bookkeeper via at: bookkeeper@lonestaraquatics.com. A $5.00 late charge will be applied if your monthly payment is not received on time. Monthly fees will not be pro-rated, unless the team schedules time off. Swim Meet participation is optional, although highly encouraged. There are additional fees associated with entering a meet. Typical fees are about $9 per event entered, plus $6 per swimmer. If you want to enter a swim meet, you must be active with the team, and your balance must be paid in full. Statements will be electronically mailed to each family at the end of each month. Payment can be made via PayPal, or by delivering a check to the poolside file box, or by mailing a check to the team s PO Box 851, Round Rock, TX Families having more than two swimmers will pay full price for the first two swimmers and one half the regular training fee for each of the lowest priced additional, immediate family members. Photo Release I give permission for representatives of the Lone Star Aquatic Club to take photographs of my child(ren) in connection with LSACrelated activities. I authorize Lone Star Aquatic Club to copyright, use and publish the same in print and/or electronically. I agree that Lone Star Aquatic Club may use such photographs of my child(ren) with or without the name identified and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. All of the above is clearly understood and agreed to by:

3 Medical Release Form & Emergency Information Swimmer s Last Name Family Doctor Phone Number Address Preferred hospital Medical Insurance Co. Policy Holder Name Policy Number Emergency Contact Name Phone Number Relationship to Swimmer Swimmer s First Name Allergies Medical Conditions List Regular Medications If you are unable to contact the doctor, please accept this letter as your authority to use the doctor on call in the Emergency Room for any necessary emergency medical treatment. I hereby give my permission and approval for participation for the above named child(ren) in any and all activities sponsored by Lone Star Aquatic Club, and I assume all risk and hazard incident to my child s(ren s) participation, including transportation to and from such activities. Accordingly, I waive, release, indemnify and agree to hold harmless the Lone Star Aquatic Club and its Coaches, Assistant Coaches, Club Officers, officials, participants and parents from any claim arising out of injury to my child(ren) while participating in any and all activities, including, but not limited to, transportation to and from all practice swim sessions, competitive swim meets and other activities sponsored by Lone Star Aquatic Club. Furthermore, I know of no impairment or deficiency, physical health or otherwise, that would limit or prohibit my child(ren) from participating in practice swim sessions and competition. I agree to advise and make known to Lone Star Aquatic Club and the Coach of any change in the physical health or any other condition that would limit or prohibit my child(ren) from participating in practice sessions, competitive swim meets, and other activities sponsored by Lone Star Aquatic Club.

4 USA SWIMMING 2016 SEASONAL ATHLETE REGISTRATION APPLICATION LSC: SOUTH TEXAS SWIMMING CHECK APPROPRIATE SEASONAL PERIOD: THIS MEMBERSHIP IS ONLY FOR MEETS BELOW SEASON 1 (April 1, 2016 to August 27, 2016 ZONE, SECTIONAL AND NATIONAL LEVELS. PLEASE PRINT LEGIBLY COMPLETE ALL INFORMATION: Previously registered with USA Swimming YES NO 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 (Bill, Beth, Scooter, Liz, Bobby) If not affiliated with a club, enter Unattached PARENT/GUARDIAN #1 LAST NAME PARENT/GUARDIAN #1 FIRST NAME PARENT/GUARDIAN #2 LAST NAME PARENT/GUARDIAN #2 FIRST NAME LSAC MAILING ADDRESS CITY STATE ZIP CODE AREA CODE TELEPHONE NO. FAMILY/HOUSEHOLD ADDRESS U.S. CITIZEN: YES NO ARE YOU A MEMBER OF ANOTHER FINA FEDERATION? YES NO IF YES, WHICH FEDERATION: OPTIONAL MAKE CHECK PAYABLE TO: HAVE YOU REPRESENTED THAT DISABILITY: RACE AND ETHNICITY (You may FEDERATION AT INTERNATIONAL A. Legally Blind or Visually Impaired check up to two choices): Your Team COMPETITION? YES NO B. Deaf or Hard of Hearing Q. Black or African American C. Physical Disability such as R. Asian MAIL APPLICATION & PAYMENT TO: amputation, cerebral palsy, S. White dwarfism, spinal injury, T. Hispanic or Latino 2016 REGISTRATION FEE mobility impairment U. American Indian & Alaska Native USA Swimming Fee $30.00 Please give application to your LSC Fee $20.00 D. Cognitive Disability such as V. Some Other Race severe learning disorder, W. Native Hawaiian & Other Pacific autism Islander Club Team for processing. TOTAL DUE $50.00 HIGH SCHOOL STUDENTS Year of high school graduation: Check if you would like to learn more about the USA YEAR LAST REGISTERED:. IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2015, ENTER THAT Swimming Foundation s initiatives CLUB CODE: LSC CODE: AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB:. Check if you would like to receive the electronic USA Swimming Newsletter (must be 13 years of age or older) SIGN HERE x SIGNATURE OF ATHLETE, PARENT OR GUARDIAN DATE REG. DATE/LSC USE ONLY

5 USA SWIMMING 2016 SEASONAL ATHLETE REGISTRATION APPLICATION LSC: SOUTH TEXAS SWIMMING CHECK APPROPRIATE SEASONAL PERIOD: THIS MEMBERSHIP IS ONLY FOR MEETS BELOW SEASON 1 (April 1, 2016 to August 27, 2016 ZONE, SECTIONAL AND NATIONAL LEVELS. PLEASE PRINT LEGIBLY COMPLETE ALL INFORMATION: Previously registered with USA Swimming YES NO 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 (Bill, Beth, Scooter, Liz, Bobby) If not affiliated with a club, enter Unattached PARENT/GUARDIAN #1 LAST NAME PARENT/GUARDIAN #1 FIRST NAME PARENT/GUARDIAN #2 LAST NAME PARENT/GUARDIAN #2 FIRST NAME LSAC MAILING ADDRESS CITY STATE ZIP CODE AREA CODE TELEPHONE NO. FAMILY/HOUSEHOLD ADDRESS U.S. CITIZEN: YES NO ARE YOU A MEMBER OF ANOTHER FINA FEDERATION? YES NO IF YES, WHICH FEDERATION: OPTIONAL MAKE CHECK PAYABLE TO: HAVE YOU REPRESENTED THAT DISABILITY: RACE AND ETHNICITY (You may FEDERATION AT INTERNATIONAL A. Legally Blind or Visually Impaired check up to two choices): Your Team COMPETITION? YES NO B. Deaf or Hard of Hearing Q. Black or African American C. Physical Disability such as R. Asian MAIL APPLICATION & PAYMENT TO: amputation, cerebral palsy, S. White dwarfism, spinal injury, T. Hispanic or Latino 2016 REGISTRATION FEE mobility impairment U. American Indian & Alaska Native USA Swimming Fee $30.00 Please give application to your LSC Fee $20.00 D. Cognitive Disability such as V. Some Other Race severe learning disorder, W. Native Hawaiian & Other Pacific autism Islander Club Team for processing. TOTAL DUE $50.00 HIGH SCHOOL STUDENTS Year of high school graduation: Check if you would like to learn more about the USA YEAR LAST REGISTERED:. IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2015, ENTER THAT Swimming Foundation s initiatives CLUB CODE: LSC CODE: AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB:. Check if you would like to receive the electronic USA Swimming Newsletter (must be 13 years of age or older) SIGN HERE x SIGNATURE OF ATHLETE, PARENT OR GUARDIAN DATE REG. DATE/LSC USE ONLY UARDIAN DATE REG. DATE/LSC USE ONLY