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Potomac Valley website: http://www.pvmasters.org
United States
UNITED STATES MASTERS SWIMMING MEMBERSHIP APPLICATION 2009 Masters
PLEASE PRINT LEGIBLY THE NAME YOU WILL USE IN COMPETITION Swimming
Last Name First Name Mid Initial Jr,Sr,III, etc O NEW REGISTRATION
O RENEW FROM PV
Street Address O RENEW (OTHER LMSC)
Previous #:
City State Zip (if known)
Fee $37
Phone Number Birthdate (mm/dd/yy) Age Sex Pay to: Potomac Valley LMSC
( ) Mail form and fees to:
Potomac Valley Club Name or Unattached O I wish to contribute $1 (or $__________) to the USMS Foundation PV LMSC
O I wish to contribute $1 (or $__________) to the Intl Swimming Hall of Fame Foundation 13548 Coachlamp Ln.
I have added these amounts to my registration fees. Silver Spring, MD 20906
O Check here if you coach Masters Swimmers.
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 CONDITON 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___________________________________________Date____________ EMAIL:_____________________________________________
$12 of the membership fee supports the PVLMSC; $8 is designated for the calendar year subscription to Swimmer magazine; $17 supports USMS.
(web version)
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? ? ? PLEASE CUT OR PROCESSING WILL BE DELAYED ? ? ?
NOTE THE FORM FIELDS AND CHECK BOXES MAY BE PRE-
FILLED IN BEFORE PRINTING.
TO REGISTER:
1. Print form and cut along dotted line.
2. Complete all information (note Club name must be a Potomac Valley registered club or you will be
listed as Unattached).
3. Sign form and mail with appropriate fees to address shown.
4. Under normal circumstances you should receive your registration card within 2 weeks after mailing it to
the PV Registrar. Please make copies of your card immediately after you receive it, as you will need
copies for meet entries, clinics and some workouts to prove your registration. Note your card is also
proof of your USMS liability insurance.
5. Replacement cards are $5.
ADDITIONAL NOTES:
1. Your USMS Registration will be valid from the date of registration through 12/31/2009.
2. If you register between September 1, 2009 and October 30, 2009 the fee is reduced to $27.
3. The donations to the two foundations are tax deductible.
4. Upon your registration you will receive two publications: The Swimmer's Ear and Swimmer magazine:
- The Swimmer's Ear is a newsletter published by the Potomac Valley LMSC. It contains local meet
announcements plus articles submitted by our members. The Swimmer's Ear is published 4 times
per year. If you do not want to receive this newsletter, (e.g. there are multiple registered PV
swimmers at your residence) please include a note with your registration.
- Swimmer magazine is published every two months. Your subscription will be valid through the
2010 Jan/Feb issue (please note there may be a delay of up to 2 months for your magazine
subscription if a printing deadline has passed). You may opt out of receiving the magazine but you
may not elect to receive credit in lieu of the subscription.
