USA SWIMMING
2017 ATHLETE REGISTRATION APPLICATION
LSC: IN (Indiana): membership valid 9.1.16-12.31.17
PLEASE PRINT LEGIBLY  COMPLETE ALL INFORMATION:
LAST NAME
LEGAL FIRST NAME
DATE OF BIRTH (MO/DAY/YR)
PREFERRED NAME
SEX (M/F)
AGE
MIDDLE NAME
CLUB CODE
NAME OF CLUB YOU REPRESENT
If not affiliated with a club, enter “Unattached”
(Bill, Beth, Scooter, Liz, Bobby)
GUARDIAN #1 LAST NAME
GUARDIAN #1 FIRST NAME
GUARDIAN #2 LAST NAME
GUARDIAN #2 FIRST NAME
MAILING ADDRESS
U.S. CITIZEN:
CITY
STATE
–
AREA CODE
TELEPHONE NO.
YES
NO
ZIP CODE
ARE YOU A MEMBER OF
ANOTHER FINA
FAMILY/HOUSEHOLD E-MAIL ADDRESS
FEDERATION? ☐ YES ☐ NO
OPTIONAL
DISABILITY:
A. Legally Blind or Visually Impaired
B. Deaf or Hard of Hearing
C. Physical Disability such as
amputation, cerebral palsy,
dwarfism, spinal injury,
mobility impairment
D. Cognitive Disability such as
severe learning disorder,
autism
RACE AND ETHNICITY (You may
check up to two choices):
Q. Black or African American
R. Asian
S. White
T. Hispanic or Latino
U. American Indian & Alaska Native
V. Some Other Race
W. Native Hawaiian & Other Pacific
Islander
HIGH SCHOOL STUDENTS – Year of high school graduation:
YEAR LAST REGISTERED:
CLUB CODE:
LSC CODE:
IF YES, WHICH FEDERATION:
MAKE CHECK PAYABLE TO:
Your club unless Unattached (Indiana
Swimming)
MAIL APPLICATION & PAYMENT TO:
2017 REGISTRATION FEE
Sept. 1, 2016 through Dec. 31, 2017
YOUR CLUB
If unattached, sent to:
Indiana Swimming
201 S Capitol Ave, Suite 410
Indianapolis,. IN 46225
. IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2016, ENTER THAT
AND THE DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB:
SIGN
HERE x ___________________________________________________________________
SIGNATURE OF ATHLETE, PARENT OR GUARDIAN
.
____________________
DATE
USA Swimming Fee
LSC Fee
$56.00
$7.00
TOTAL DUE
$63.00
Check if you would like to learn more about the USA
Swimming Foundation’s initiatives
Check if you would like to receive the electronic USA
Swimming Newsletter (must be 13 years of age or older)
REG. DATE/LSC USE ONLY ____________________
This form is to be returned to YOUR CLUB with payment. Your club will send one payment to our office for
all registrations submitted. Only if you are a true unattached athlete (you do NOT belong to a club) should you
send this completed form with payment directly to our offices.
Birth Certificate Copy Needed: ****Since 2010, Indiana Swimming has required all 18 and younger swimmers to submit a COPY
of their birth certificate to their club registrar. Swimmers who do not submit a copy of the birth certificate and subsequently swim in
meets will be assessed a $100 per meet fine for non-compliance/confirmation of age. Once Indiana Swimming has confirmed the
swimmer’s membership with date of birth confirmation, the swimmer will NOT have to re-submit. If you are unsure if Indiana
Swimming has your date of birth confirmed from a previous year’s membership, please e-mail [email protected]. **Indiana
Swimming does accept other forms of date of birth confirmation. Please see CLUB FORMS section of the website for the Birth
Certificate Requirements document.
QUESTIONS regarding your club practices, times, fees, ect need to be directed to your club, not our offices.
This form should be completed for EVERY ATHLETE MEMBER of Indiana Swimming. Completing these forms is a requirement of
USA Swimming and gives your club liability insurance and your swimmer some secondary accident insurance. Clubs should keep
these signed forms in the club files. Clubs are asked to submit team management software files (Team Manager or Team Unify) to
register the athletes. Please e-mail [email protected] for questions/details.