Registration Status: New Registration:____ or Renewal:____ last know USMS Number:
Last Name                                                First Name                                                          MI
Mailing Address
City	State	Extended Zip	home phone number (              )
Date of Birth Month              Day              Year	Age	Sex	Today's Date Month              Day              Year
Club affiliation: North Carolina Masters Swimming Club (default), NC workout group, or unattached

Note: if you not sure about the workout group name, refer to NC's team list or the list at the bottom of this page.

WAIVER: "I, the undersigned participant, intending to be legally bound, hereby certify that I am physically fit and have not been otherwise informed by a physician. I acknowledge that I am aware of all the risks inherent in Masters Swimming (training and competition), including possible permanent disability or death, and agree to assume all of those risks. AS A CONDITION OF MY PARTICIPATION IN THE MASTERS SWIMMING PROGRAM OR ANY ACTIVITIES INCIDENT THERETO, I HEREBY WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES, INCLUDING ALL CLAIMS FOR LOSS OR DAMAGES CAUSED BY THE NEGLIGENCE, ACTIVE OR PASSIVE, OF THE FOLLOWING: UNITED STATES MASTERS SWIMMING, INC., THE LOCAL MASTERS SWIMMING COMMITTEES, THE CLUBS, HOST FACILITIES, MEET SPONSORS, MEET COMMITTEES OR ANY INDIVIDUALS OFFICIATING AT THE MEETS OR SUPERVISING SUCH ACTIVITIES. In addition I agree to abide by and be governed by the rules of USMS."

Signature(required):_____________________________________ Today's Date (mo/day/yr):____/_____/_______

Use of Image/Likeness: I grant permission to U.S. Masters Swimming and its affiliates to use my likeness and/or image in photographs, video, motion pictures, recordings, or any other record for legitimate purpose.

Please check:coach USMS swimmers ____ , certified official ___ , YMCA ____, USA Triathlon _____ , USA Swimming ____

If you have an E-Mail Address, please clearly print it here _________________________________________

A link to the quarterly NC Newsletter will be sent via email to save paper and postage, if you must have it mailed, please check ____

Registration and benefits of membership from this application will expire on December 31, 2010.

Benefits of membership include: A subscription to USMS's magazine, SWIMMER during the length of the membership year ($8.00 of the annual USMS dues is designated for the magazine subscription, and is non-refundable or pro-rated), and periodic mailings from the LMSC for NC.

USMS Registered swimmers are covered with secondary accident insurance.
1) In practices supervised by a USMS member or USA Swimming certified coach where all swimmers are USMS registered.
2) in USMS sanctioned meets where all competitors are USMS registered.

_____	I wish to contribute $1.00 (or $ _______) to the International Swimming Hall of Fame Foundation. I have added this amount to my 2010 registration fees
_____	I wish to contribute $1.00 (or $ _______) to the United States Masters Swimming Foundation. I have added this amount to my 2010 registration fees
_____	I wish to contribute $1.00 (or $ _______) to North Carolina Masters Swimming Club. I have added this amount to my 2010 registration fees

Submit the above signed form, along with a check for $37.00 ($27 USMS fee, $10 LMSC for NC fee) made payable to LMSC for NC plus any contributions listed above.
If you register in 2010 between 9/1/2010 and 10/31/2010, the fee is reduced to $27 ($22 USMS, $5 LMSC), otherwise you owe the full $37 payable to LMSC for NC.
Mail to:

George S. Simon
Registrar, LMSC for NC
10229 Boxelder Dr
Raleigh, NC 27613-6139