US Masters Swimming 2012 Metropolitan LMSC USMS Registration ...

U. S. Masters Swimming
2012 Metropolitan LMSC
Late Season (September & October only)
USMS Registration Form
G RENEWAL my last USMS number was: ______________-____________________
This box for office use only
Check or Money Order Number
Date Entered
Assigned 2012 USMS Registration Number
G I am a NEW Registrant
_____________________________
__________/___________/___________
# 0 6 2 ___________________________________________________
Register with the same name you will use for competition. Please print clearly. A legible email address is important since email
is our primary form of communication. All information fields must be filled in. Incomplete or illegible forms can not be processed.
LAST Name FIRST Name Middle Initial
Street Address (include apartment, suite or floor number if applicable)
City State Zip
Preferred Phone (include area code)
Date of Birth m m / d d / y y y y
Gender (circle one)
Age
(_________)___________-___________________
_______/________/______________
Male
Female
Club Code (see page 2 for club code listing)
E-Mail Address (print clearly):
_______ _______ _______ _______
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, recordings, or any other
record for legitimate purpose.
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 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 of USMS.”
Signature (required) ________________________________________________________
Date (required) _____________________________
Check all that apply: G I am a USMS swim coach G I am a USA-Swimming certified official
I am a member of: G American Swimming Coaches Association G USA-Swimming G USA-Triathlon
USMS-registered members are covered with secondary accident insurance in practices supervised by a USMS member or USA-Swimming certified
coach wherein all swimmers are USMS registered, and in USMS-sanctioned events wherein all competitors are USMS registered. Benefits of USMS
membership include a subscription to USMS SWIMMER magazine for the duration of current membership year.
$35.00 total registration fee if paid between September 1, 2012 and October 31, 2012 plus any additional donations indicated below. 2012 USMS
registration is valid to December 31, 2012.
G I wish to contribute $1.00 or $____________ (indicate amount) for the Metropolitan Local Masters Swimming Committee
G I wish to contribute $1.00 or $____________ (indicate amount) for the U. S. Masters Swimming Endowment Fund
G I wish to contribute $1.00 or $____________ (indicate amount) for the International Swimming Hall of Fame Foundation
$35.00 registration fee plus indicated donation(s) payable via check or money order to METROPOLITAN LMSC. Mail payment with
fully executed form to: Mary Fleckenstein, 99 Sheep Pasture Road, Port Jefferson, NY 11777. Allow two (2) weeks processing time.
Direct all registration inquiries to metroreg@gmail.com. General registration information is available online at www.metroswim.org.

Page Two Metropolitan LMSC 2012
USMS LATE Season Registration
INDEPENDENT CLUBS & CODES
Stand-alone independent clubs. Swimmers may participate on relays and score points at meets only
with members of the same club. Unattached (UNAT) swimmers are NOT eligible for relay participation.
ATOM
AGUA
BDGR
BCTM
BRAT
CHEL
Aquatics Team of Manhattan
Asphalt Green Masters
Badger Masters
Bearcat Masters
Bay Ridge Aquatics Team
Chelsea Piers Masters
EAST East End Masters POST POST Swimming
XCEL EXCEL Swimming REDT Red Tide of NYC Masters
FISH FISH Masters RIMS Roosevelt Island Masters Swimming
HUMS Huntington Masters SEAW Seawolves Masters
HDRO HYDRO Masters TNYA Team New York Aquatics
LIEM LI Express Masters WM Westchester Masters
CTRI
Columbia Tri Masters
NYCH
NYC Hydras
CIBB
Coney Island Brighton Beach
Open Water Swimmers
OWS Open Water Swim UNAT Unattached (NO relay eligibility)
METRO = Metropolitan Masters All-Star Team with Workout Group CODES
Comprised of Metro workout groups, teams and Unattached-Metro (UNAM) swimmers
who may participate together on relays and for point-scoring purposes at swim meets.
BNLA BNL Accelerators SOFM South Fork Masters WAVE WAVE Ryeder Masters
HHB Harlem Honeys & Bears TRS Team Rockland Swimming WSYM West Side YMCA Masters
MBYM McBurney YMCA Masters TTT Team Total Training YONM Yonkers Masters
PARK Parkwood Swimming VYMM Vanderbilt Masters
PREM Premier Aquatics Masters CKNO Wall Street Titans
UNAM
Unattached-Metro (relay eligibility
with swimmers from all Metro Masters
All-Star Team Workout Groups)
For additional registration information, visit the Metropolitan LMSC website at www.metroswim.org,
or contact the Metropolitan LMSC Registrar Mary Fleckenstein via email at metroreg@gmail.com,
or send inquiries and correspondence to: 99 Sheep Pasture Road, Port Jefferson, NY 11777.
Updated 08.31.12