2012RegistrationForm.xls - Ohio LMSC - Home Page

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2012RegistrationForm.xls - Ohio LMSC - Home Page Powered By Docstoc
                                           You can also register online and print copies of your membership card at usms.org

Please check only one:
                    New Registraion
                    Renewal Registration                                           Current USMS #

Important: Register with the name you will use when you enter meets. PLEASE PRING CLEARLY!

Last Name                                                                              First Name                                         Middle Initial

Street Address:

City, State, Zip:

Home Phone:                                                          Work Phone:                                     Fax #

Date of Birth                                                               Age:                              Gender: (circle one)             Male           Female

Email Address:

                    CLUB AFFILIATION
                    If no club is selected, you will be registered
                    as UNATTACHED.                                                                                  FEES:
                        UNATTACHED                                                                                                        USMS fullyear registration - $35
                                                                                                                                          (covers from Nov. 1, 2011 thru Dec 31, 2012
                        BGSC (Bowling Green Swim Club)

                        BGSU (Bowling Green State Univ. Masters)                                                                          Fall Registration - $28
                                                                                                                                          if registering for 2012 after Sept. 1, 2012
                        CiSC (Cincinnati Sports Club Masters)

                        CSMT (Columbus Sharks Masters)                                                                                    I wish to contributer $1.00 (or $_______) to
                                                                                                                                          the International Swimming Hll of Fame
                        DAS (Dayton Area Sharks)                                                                                          Foundation. I have added this amount to
                                                                                                                                          my 2012 registration fee.
                        DISC (Discovery Swim School)

                        DRM ( Dayton Raiders Masters)                                                                                     I wish to contributer $1.00 (or $_______) to
                                                                                                                                          the USMS "Swimming Saves Lives" Fund.
                        DYD (Downtown YMCA Dolphins)                                                                                      Foundation. I have added this amount to
                                                                                                                                          my 2012 registration fee.
                        HMSA (Hancock Masters Swimming)

                        HURY (Hilliard YMCA Hurricanes)                                                             TOTAL FEES ENCLOSED $ __________________________

                        MHHC (McConnell Masters)                                                                                   Make checks payable to: OHIO LMSC

                        NAM (New Albany Aquatics Club)                                                              Mail your check, and a SASE (self-addressed, stamped envleope) and this
                                                                                                                    completed form to:
                        OHSP (Ohio Splash)                                                                                          Laura Wright

                        OUMS (Ohio University Masters Swim Team)                                                                          Ohio LMSC Registrar

                        SPY (Springfield YMCA)                                                                                            312 East Mulberry St.

                        SWOM (Southwest Ohio Masters)                                                                                     Lancaster, OH 43130

                             ABM (Anderson Barracuda Masters)

                             BAY ( Blue Ash YMCA)

                             CMM (Cincinnati Marlin Master)                                                         RELEASE FROM LIABILITY

                             EBCY (East Butler County YMCA                                                          I, the undersigned participant, intending to be legally bound, hereby certify that I am physically fit and

                             MCYM (Miami County YMCA Masters                                                        have not been otherwise informed by a physician. I acknowledge that I am aware of all the risks

                             MHSW (Mercy Healthplex Sea Wolves)                                                     inherent in Masters Swimming (training and competition), including possible permanent disability or

                             MRM (Miami Redfin Masters)                                                             death, and agree to assume all those risks. AS A CONDITION OF MY PARTICIPATION IN THE

                             RAYS (Mason Manta Ray Masters)                                                         MASTERS SWIMMIN PROGRAM OR ANY ACTIVITIES INCIDENT THERETO, I HEREBY WAIVE

                             UCM (University of Cincinnati Masters)                                                 ANY AND ALL RIGHTS TO CLAIMS FOR THE LOSS OR DAMAGES, INCLUDING CLAIMS FOR

                             WTRC (Washington Twp. Rec Center)                                                      LOSS OR DAMAGES CAUSED BY THE NEGLIGENCE, ACTIVE OR PASSIVE, OF THE FOLLOWING:

                             XTC (Xavier Triathalon Club                                                            UNITED STATES MASTERS SWIMMING, INC., THE LOCAL MASTERS SWIMMING COMMITTEES,

                             **Other________________                                                                THE CLUBS, HOST FACILITIES, MEET SPONSORS, MEET COMMITTEES, OR ANY INDIVIDUALS

                        SYL (Sylvania Masters Swim Club)                                                            OFFICIATING AT THE MEETS OR SUPERVISING SUCH ACTIVITIES. In addition, I agree to

                        UAMS ( Upper Arlington Masters Grey Bears)                                                  abide by and be governed by the rules of USMS.

                        UAR ( Up and Running Swim & Tri)

                        WSM (Wright State Masters)                                                  SIGNED:
                        *OTHER _____________________
                                                                                                    Ohio LMSC communications are now only available via the LMSC website (http://www.ohiolmsc.org/) and e-mail.
                    *NOTE on "OTHER": To be added to this list, the                                 Benefits of Membership include: A sub
                    registrar must have a completed registration form
                    and the annual fee of $35.
                    ** for new workout groups with SWOM, registrar
                    needs the name of a contact person.

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