2012 One Year Membership Application Gulf Region - administered by the Gulf Masters Swim Committee (GMSC) (http://www.GulfMastersSwimming.org) I have been registered with USMS in the past (Old number, if known:

)

New Registration . . . You can also register or re-register online at http://www.usms.org Register with the same name you will use for competition. Please print clearly with a black pen

Name

First

Initial

Address

Street

Masters Coach

Last

Certified Official (certifying body:

City

Phones

Suffix (Jr., III, etc.)

)

State

Zip

Country (other than US)

Home

Work

Cell

Fax

Pager

Other

Age/Gender

Date of Birth

Club

If left blank, you will be registered unattached (UNAT)

Mo.

Age Day

Gender (M/F)

Yr.

Email(s)

Primary Secondary

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

Date: Mo.

Fees

(May be reduced to $26 on 1 Sep 12, thereafter)

NOTES: a) All registrations will expire on 31 Dec 12.

Donation to the

b) Registrations after 31 Oct 12 can be registered as 2013 members.

Donation to the

USMS "Swimming

USMS Fee:

$

31

GMSC Fee:

$

9

Saves Lives" Fund

Day

Yr.

Make cheque payable to:

GMSC Mail this form and cheque to:

($1 suggested):

$

International Swimming Hall of Fame ($1 suggested):

$

(Chq. No.: __________ Date: _______________) Total:

$

GMSC Registrar P.O. Box 7084 The Woodlands, TX 77387-7084 Registrar: Scott Campbell - [email protected]

Benefits of Membership include: A Subscription to USMS’s magazine, USMS SWIMMER, during the length of the membership year ($8.00 of the annual dues is designated for the magazine subscription) and periodic mailings from the GMSC. USMS Registered swimmers are covered with secondary accident insurance in practices supervised by a USMS member or USA Swimming certified coach where all swimmers are USMS registered and in USMS sanctioned meets where all competitors are USMS registered. If your club / team swims in more than one facility, please list the pool(s) where you swim:

Registered Clubs in the Gulf LMSC in 2011: Club Brazos Splash Masters ConocoPhillips Masters Swim Team Conroe Aquatic Masters Cy-Fair Swim Club Dad's Club Swim Team Masters ETEX Masters Swim Team First Colony Masters Swimming Fort Bend Masters Swimming H2Ouston Swims

Abbrv BSM COPM CAM CFSC DADS ETEX FCST FBMS H2O

& No. 35 46 43 36 20 13 23 2 5

Club Houston Cougar Masters Katy Aquatic Masters Swimming Masters Of Brazos Memorial Athletic Club Aquatics North Channel Aquatic Masters Pearland Aquatics Premier Aquatic Masters Rice Aquatic Masters Sienna Plantation Aquatic Masters

Abbrv COOG KAMS MOB MACA NCAM PEAQ PACK RICE SPAM

& No. 47 11 6 10 40 42 29 18 30

Club South Belt Area Allstars Swimming Team South Shore Sails Masters Swimming South Texas Flying Fish South West YMCA Masters The Houstonian Club Trotter Family YMCA Weekley Houston YMCA Wellness Masters Swim Club Woodlands Masters Swim Team

Should you have any questions, your Registrar is Scott Campbell, [email protected] or call 281 844 3838 (cell)

Abbrv SBAS SSSM STFF SWYM HOST TFY WHY WSMC WMST

& No. 28 41 1 21 8 16 33 45 7