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

I acknowledge that I have reviewed and agree to abide by rules and regulations of the Minor Athlete Abuse Protection Policy and I have completed Athlete Protection Training.* 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 BSPL BSY BULL CAC CAT CDOG CPAC FFLY FINS FVYT GLAS GRIT GRYM GWYB GYWD HHAC IVY LEHY LST MAC MJCC MSC NCA NCY NFAF NMBS NMEG NSC NWYL OAK ORCA OXO PAC PSDY RAC RAYS RST RYWC SAQ SEAL SHKS SJCC SLAC SSAC SWAT SYS TAC TP UN VSYM WAC WEST WFYD WHAT WHSC WRAT WRTS WWRX WYW 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 and phone numbers are not published.

Membership Type. Check all that apply.

Check all that apply:

Official

Junior Coach Ages 16 and 17

Coach Part-Time (Primary Employment is NOT coaching.)

Coach Full-Time (Employed full time as a coach)

Other (Chaperone, Meet Director, etc.)

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

I understand that it takes 1-2 business days to process my application.* Yes

This completes your application. Individual membership is $78. 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: Henk Jansen, 68 Nichols Ave, Shelton, CT 06484. Please put "Non-Athlete Membership" on the memo line. Only registrations with payment will be processed. Questions regarding membership should be addressed to your CSI Registrar. Will payment be by credit card or check?* Credit Check

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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