2021 USA Athlete Membership

Which Membership are you registering for *

LAST NAME *

LEGAL FIRST NAME *

MIDDLE NAME

PREFERRED NAME

DATE OF BIRTH *

Date

AGE

SEX *

ARE YOU A US. CITIZEN

YES NO

CLUB CODE *

Enter UN if unattached

NAME OF CLUB YOU REPRESENT *

if your not affiliated with a club enter Unattached

NOTE: If you are 18 years of age or older, you are required to abide by to the Minor Athlete Abuse Prevention Policy. In addition, in order to be a member in good standing, you must complete the Athlete Protection Training. The training can be accessed at www.usaswimming.org/apt

GUARDIAN #1 LAST NAME

GUARDIAN #1FIRST NAME

GUARDIAN #2 LAST NAME

GUARDIAN #2 FIRST NAME

MAILING ADDRESS *

CITY *

STATE *

ZIP CODE *

Phone Number

Area Code Phone Number

FAMILY EMAIL ADDRESS

example@example.com

MEMBERS EMAIL ADDRESS *

example@example.com

ARE YOU A MEMBER OF ANOTHER FINA FEDERATION

YES (IF YES, WHICH FEDERATION) NO

FINA FEDERATION

HAVE YOU REPRESENTED THAT FEDERATION AT INTERNATIONAL COMPETITION

YES NO

DISABILITY: OPTIONAL

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 GRADUATION

YEAR LAST REGISTERED WITH USA Swimming

YEAR OF GRADUATION

IF YOU REGISTERED WITH A DIFFERENT USA SWIMMING CLUB IN 2019, ENTER THAT CLUB CODE AND LSC CODE

ENTER DATE OF YOUR LAST COMPETITION REPRESENTING THAT CLUB:

APPROPRIATE PAPERWORK SHOWING LSC QUALIFICATIONS FOR THIS OUTREACH REGISTRATION MUST BE ATTACHED TO THIS FORM IN ORDER TO PROPERLY REGISTER THIS ATHLETE

Outreach Registration Qualifications

Please provide of one of the following: Redacted copy of Federal Tax return showing income below Federal Reduced School Lunch income Eligibility guidelines.

or

Copy of one of the following proof of assistance:

Aid to Families with Children Social Security Disability Insurance, Food Stamps, temporary Assistance to Needy Families,Supplemental Security Income, Women, Infant and Children’s Program (WICK), Medicaid, Children’s Health Insurance Plan, Section 8 Public Housing, Home Energy Assistance Program, Free/Reduced School Lunch

Please upload proof of Outreach *

Browse Files

Signature

SIGNATURE OF ATHLETE, PARENT OR GUARDIAN Clear

Date

Check if you would like to learn more about the USA Swimming Foundation's initiatives

YES

Check if you would like to receive the electronic USA Swimming Newsletter (must be 13 years of age or older)

YES

Are you paying by Credit?

Yes No

Please print the form and mail a check for the correct amount to:

** NO CASH IS ACCEPTED!

Metropolitan Swimming

99 Sheep Pasture Rd

Port Jefferson, NY 11777

Membership Selection

Premium Membership $ 76.00

Flex Membership $ 20.00

18&U only!

Outreach Membership $ 5.00

Single Meet Membership $ 22.00

Flex Upgrade $ 54.00

Life Time $ 1,014.00

Total $ 0.00

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