New Member and "Other" Volunteer Renewal Application

By becoming a member of USA Swimming, I hereby agree to abide by the rules, regulations and Code of Conduct of USA Swimming.* Yes

I acknowledge that when I learn of facts that give reason to suspect that a child has suffered an incident of abuse, including sexual abuse, I must report to law enforcement within 24 hours pursuant to The Protecting Young Children from Sexual Abuse and Safe Sport Authorization Act.* Yes

Contact Information

Last Name:*

Legal First Name:*

Middle Name (If no middle name, enter None):*

Preferred First Name:

Have you ever been a member of USA Swimming under a different last name?* Yes No

If at anytime registered in a different LSC, which LSC:

Date of birth (mm-dd-yyyy):*

Gender:* Female Male

Club Code:* AJSC ARAC BEAR BSY BULL CAC CAT CCAT CCSU CDOG CPAC FFLY FINS FVYT GLAS GRIT GRYM GWYB GYWD HHAC HMST HNHS HNHY ICSC IVY LEHY LST MAC MJCC MSC NCA NCY NFAF NMBS NMEG NSC NWYL OAK OXO PAC PSDY RAC RAYS RYWC SAQ SEAL SHKS SJCC SLAC SMST SOCO SSAC SYS TAC TP UCON UN VSYM WAC WEST WFYD WHAT WOLF WRAT WRTS WWRX WYW YALE YCST ZEUS

Street:*

City:*

State:*

Zip Code:*

Phone (xxx-xxx-xxxx):

Mobile Phone (xxx-xxx-xxxx):

Email:*

Officials may opt out of listing phone, email, or both in Connecticut FAST database queries. Officials without contact information listed may not be contacted by meet hosts to officiate. Officials without email cannot create a Connecticut FAST My Account, will not receive electronic newsletters, and will not receive emails from USA/CT Swimming. Email Opt Out Officials Query Phone Opt Out Officials Query Email & Phone Opt Out Officials Query

Coach email addresses are not published.

Membership Type. Check all that apply.

Check all that apply:

Official (Requires Background Check and Athlete Protection Training)

Junior Coach Ages 16 and 17 (No background check required, requires Athlete Protection Training)

Coach Part-Time (Requires Background Check and Athlete Protection Training)

Coach Full-Time (Requires Background Check and Athlete Protection Training)

Other (Requires Background Check and Athlete Protection Training)

If coach, primary age group that you coach (may be more than one):

10/Under

11/12

13/14

15/18

19+

Masters

Race and Ethnicity (optional and may select up to 2 choices):

Black or African American

Asian

White

Hispanic or Latino

American Indian & Alaska Native

Native Hawaiian & Other Pacific Islander

Some Other Race

Other

Please call USA Swimming 719-866-4578 if you do not wish to receive marketing partner mailings.

Would you like to learn more about the USA Swimming Foundation’s initiatives? Yes No

Would you like to receive the electronic USA Swimming Newsletter? Yes No

Payment

This completes your application. Individual membership is $75. If you select credit card payment, you will be automatically directed to the payment site. If you select check, please upload a check image and send the check (payable to CT Swimming) to: Ginger McCurdy, 28 Farms Village Rd, Wethersfield, CT 06109. Please put "Non-Athlete Membership" on the memo line. Only registrations with payment will be processed. Please allow 1-2 business days for processing this application. Questions regarding certification should be addressed to your CSI Registrar. Will payment be by credit card or check?* Credit Check Someone else is paying

Membership Card

Your USA Swimming membership card or coach card will be sent digitally via USA Swimming's mobile app Deck Pass.

Question/Comments:

By submitting this application I verify that the above is true and correct.

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