Outreach Meet Fee Support Request

Outreach Meet Fee Support Request
Contact Information

Please provide contact information for the person making the request.
Club Name*
Name*

First NameLast Name
Email*
example@example.com
Meet Fee Reimbursement
Name of Meet*
First Day of Meet*

MonthDayYear
Date
I agree that all of the following athletes listed are registered with USA Swimming as Outreach Athletes.*

Yes

Total Entry Fees:

	Athlete Name	Total Number of Individual Entries	Fee Per Individual Entry ($)	Total Cost of Entry Fees ($)
1
2
3
4
5
6
7
8
9
10
11
12

Total Submitted ($)
Total Amount to be sent to Host Club (50%) $
Remittance

Please provide to whom to remit reimbursement
Club to Make Check Payable to: *
Club Name
By signing below, you attest that all information provided in your request is true and accurate. In addition, your request is in accordance with the Bylaws and Policies and Procedures of Ozark Swimming, Inc.

You also agree to send proof of swims to Treasurer after the meet.
Signature*

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Name of Signer*

First NameLast Name
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Contact Information