UNAT FACT 2009 registration

2009 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

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

Club 010 - Florida Aquatic Combined Team (chapter UNAF)
Florida LMSC Newsletter

I have changed my address within the last year ..........
I coach Masters I am certified official
by postal mail, by email,

I am a USMS memberand my USMS number is
or don't send

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, 2008-Dec. 31, 2009)

(red area optional; white area 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 United States Masters Swimming Foundation

USMS/LMSC fee $.....33.00
If registering between 9/1/09-10/31/09, deduct $5 from fee, but membership effective only until 12/31/09

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 fee $. ....3.00

TOTAL
$

P A Y M E N T . I N F O R M A T I O N

Mail this original form with a check for $33 payable to Florida LMSC to FL LMSC registrar Meredith Moore, 8846 Mariposa Ct., Naples FL 34113.
Then, mail a separate check for $3 payable to FACT with a copy of this completed form to FACT registrar Marianne Bradley, 869 Manning Road, Palm Harbor FL 34683.

	2009 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
R E G I S T R A T I O N . I N F O R M A T I O N
Club 010 - Florida Aquatic Combined Team (chapter UNAF)			Florida LMSC Newsletter
I have changed my address within the last year .......... I coach Masters I am certified official			by postal mail, by email,
I am a USMS memberand my USMS number is			or don't send
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, 2008-Dec. 31, 2009)
(red area optional; white area 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 United States Masters Swimming Foundation
USMS/LMSC fee	$.....33.00	If registering between 9/1/09-10/31/09, deduct $5 from fee, but membership effective only until 12/31/09 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 fee	$. ....3.00

TOTAL	$
P A Y M E N T . I N F O R M A T I O N
Mail this original form with a check for $33 payable to Florida LMSC to FL LMSC registrar Meredith Moore, 8846 Mariposa Ct., Naples FL 34113. Then, mail a separate check for $3 payable to FACT with a copy of this completed form to FACT registrar Marianne Bradley, 869 Manning Road, Palm Harbor FL 34683.