| Registration Status: New Registration:____ or Renewal:____ last know USMS Number: | |||
| Last Name
First Name
MI
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| Mailing Address |
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| 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
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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):____/_____/_______
Please check: Masters coach ____ , certified official ___ , I am a member of YMCA ____, USA Triathlon _____ , USA Swimming ____
If you have an E-Mail Address, please clearly print it here _________________________________________
NC Newsletter will be sent via email monthly as well as notifications of upcoming NC swim events
Registration and benefits of membership from this application will expire on December 31, 2013.
Benefits of membership include: A subscription to USMS's magazine, SWIMMER during the length of the membership year.
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 2013 registration fees | ||
| _____ | I wish to contribute $1.00 (or $ _______) to the
USMS "Swimming Saves Lives" Fund. I have added this amount to my 2013 registration fees
| _____ | I wish to contribute $1.00 (or $ _______) to
North Carolina Masters Swimming Club.
I have added this amount to my 2013 registration fees | |
Submit the above signed form, along with a
check for $43.00
($33 USMS fee, $10 LMSC for NC fee) made payable to NC Masters Swimming Committee
plus any contributions listed above.
If you register in 2013
between 9/1/2013 and 10/31/2013, the fee is reduced to $33 ($28 USMS, $5 LMSC), otherwise you owe the full
$43 payable to NC Masters Swimming Committee.
Mail to:
George S. Simon
Registrar, LMSC for NC
10229
Boxelder Dr
Raleigh, NC 27613-6139
Please allow two weeks for processing of mailed in registration forms Or you may obtain your registration number and print your card by registering online and pay via credit card, make sure you choose North Carolina and North Carolina Masters Swimming Club, and choose your workout group. clicking here to register online for North Carolina - thank you.
| Organization/Team | Location | Total | Contact | |
| Unattached | Unattached | $43 | George Simon 919 264-3490 | |
| Clubs: | ||||
| North Carolina Masters Swimming | Unattached | $43 | George Simon 919 264-3490 | |
| Workout Groups (chapters) of NCMS Club: | ||||
| Asheville Masters Swimming (AMS) | Asheville | $43 | Kemp Battle 828 251-0596 | |
| Bowker Aquatic Club (BAC) | Winston-Salem | $43 | Chris Bowker 336 406-7174 | |
| Burke/Unifour Masters Swimming (BUMS) | Valdese | $43 | Linda Kidd 828 874-0847 | |
| Charlotte SwimMasters (CSM) | Charlotte | $43 | Bernie White 704 364-2141 | |
| Childress Klein YMCA Masters (CKY) | Charlotte | $43 | Ellie Paterno 704 716-6400 | |
| ClubWorx Masters Swimming (WORX) | Fuquay-Varina | $43 | Maura Bledsoe 919 567-3400 | |
| Cape Fear Aquatic Club (CFAC) | Wilmington | $43 | Jonathan Washburn 910 352-2846 | |
| Duke Aquatics (DUKE) (formerly Tar Heel Aquatic Team) | Durham | $43 | Eric Steidinger 919 968-0303 | |
| Durham Area Masters Aquatics (DAMA) | Durham | $43 | Dawn Franklin 919 724-1319 | |
| Enfinity Aquatic Club (EAC) | Winston Salem | $43 | Tim Hillen 336 782-4282 | |
| Fireball Masters Swimming (FMS) | Winston Salem | $43 | Alex Black 336 721-4899 | |
| Fort Bragg Masters (FBM) | Fort Bragg Military Base | $43 | Celia Wolff 910 643-8533 | |
| Gaston Gators (GG) | Gastonia | $43 | Michael Dickson 704 865-3943 | |
| Goldsboro YMCA Masters Swim Team (GOLD) | Goldsboro | $43 | Tammy Yates 919 778-8557 | |
| Greensboro Community YMCA Masters (GCYM) | Greensboro | $43 | Mary Young 336 478-9622 x235 | |
| Greensboro Swimming Association Masters (GSAM) | Greensboro | $43 | Kate Macintosh 336 851-2848 | |
| Greenville Swim Club Masters (GSCM) | Greenville | $43 | Casey Charles 252 341-1044 | |
| HealthQuest Masters (HQM) | Smithfield | $43 | Michael Rogers 919 938-7161 | |
| High Point Swim Club (HPSC) | High Point | $43 | Aaron Reeves 336 887-4772 | |
| James J Harris YMCA Masters (HARY) | Charlotte | $43 | Martha Murrah 704 716-6800 | |
| SwimMAC Masters (MAC) | Charlotte | $43 | Bill Davis 704 577-4012 | |
| Mecklenburg Swim Association Masters (MSAM) | Charlotte | $43 | Patty Waldron 704 622-4989 | |
| New River Phrogs (NRP) | Jacksonville, NC | $43 | Sarah Sweatman 910 382-5319 | |
| North Carolina Aquatic Masters (NCAM) | Chapel Hill | $43 | Sean Quinn 919 933-4905 | |
| North Mecklenburg Aquatics Masters (NMAM) | Huntersville | $43 | Steve Billings 704 949-1555 | |
| One Step Beyond Cary Masters (OSBC) | Cary | $43 | Marty Gaal 919 975-5274 | |
| Outer Banks Family YMCA Masters (OBXM) | Nags Head | $43 | Jeff Nerret 252 449-8847 | |
| Performance Aquatics by Compass Elite | Triad Area | $43 | Matthew Clancy 336 543-8771 | |
| Raleigh Area Masters (RAM) | Raleigh | $43 | George Simon 919 264-3490 | |
| Rocky Mount YMCA Masters (RMYM) | Rocky Mount | $43 | Vickie Payton 252 972-9622 | |
| Sailfish Aquatics Masters (SAIL) | Concord | $43 | Cathy Sheafor | |
| Seahawk Aquatics Club Masters (SAC) | Wilmington | $43 | Brian Benfer 910 794-7901 | |
| Siskey Family YMCA Masters Swim Team (SYMA) | Matthews | $43 | Ame Mauney 704 716-4261 | |
| Sports Center of Morehead Masters (SCMM) | Morehead City | $43 | Erika Burgess 252 646-6993 | |
| Stingray Aquatics (SAM) | Matthews | $43 | Shelley Bear 704 579-1966 | |
| Swim Fanatics Swim Masters (SFSM) | Greensboro | $43 | Sasha Kuznezov 336 354-9900 | |
| The Lowe's YMCA Masters (TLYM) | Mooresville | $43 | David Tucker 704 662-8792 | |
| Triad Masters Swimming (TMS) | Greensboro | $43 | Andrew Richelson 336 540-8774 | |
| Twin Rivers YMCA Masters (TRYM) | New Bern | $43 | Greta van Meeteren 252 745-9836 | |
| TYDE Masters Swim Team (TYDE) | Winston Salem | $43 | Leann Day 336 721-2100 | |
| Winston Salem Area Masters (AWSM) | Winston-Salem | $43 | John Pence 336 650-7482 | |
| YMCA of Rowan Aquatics & Triathlon (YRAT) | Salisbury | $43 | Sarah Zander 704 202-5562 | |
| YMCA Seahorse Swim Team (YSST) | Hickory | $43 | Rob Scott 828 320-8620 | |
| YMCA of the Triangle Area (YOTA) | Raleigh | $43 | Chad Onken 919 832-9088 x 2 |
To return to the Masters Swimming in North Carolina
Home Page
July 23, 2012
http://www.NCmasters.org/forms/generic12.html