Club Membership Application

USA SWIMMING

CLUB MEMBERSHIP APPLICATION

GULF SWIMMING 2017

The ______hereby makes application for membership in Gulf Swimming of USA Swimming, Inc. Enclosed is a team check for the annual dues. If accepted as a club member, the team agrees to abide by the Bylaws of Gulf Swimming and USA Swimming, Inc., and to respect, abide by, and enforce all decisions of Gulf Swimming and USA Swimming, Inc.

CLUB CODE: CLUB NAME:

NAME OF OWNER/BUSINESS/LEGAL ENTITY IF DIFFERENT FROM CLUB NAME:

1. 4.

2. 5.

3.

CLUB SETTING: o Rural o Suburban o Urban

NEAREST MAJOR CITY: CLUB WEB SITE:

PRE-EMPLOYMENT SCREENING

o By checking this box and signing below, I formally acknowledge that this club is conducting a pre-employment screening on all new employees who are required to be members of USA Swimming as required in the USA Swimming Rules & Regulations, Article 502.6.8.

Signature: Printed Name: Date:

Failure to check this box and sign this statement will result in the club application being rejected.

RACING START CERTIFICATION

o By checking this box and signing below, I formally acknowledge that this club complies with all Racing Start Certification requirements as stated in the USA Swimming Rules & Regulations, Article 103.2.2 and maintains records for its athlete members.

Head Coach Signature: Printed Name: Date:

Failure to check this box and sign this statement will result in the club application being rejected.

Club Information (This should include the permanent address and phone number of the team.)

CLUB CODE ______CLUB NAME ______

MAILING ADDRESS ______

CITY ______STATE ______ZIP ______

PHONE ______FAX: ______

FACILITY NAME: ______FACILITY PHONE: ______

FACILITY ADDRESS: ______

POOLS AT THIS FACILITY (if additional space is needed, use separate page and attach to application):

Pool 1: Length _____ ÿ Yards ÿ Meters Width: _____ ÿ Yards ÿ Meters ÿ Indoor ÿ Outdoor

# of Lanes: _____ # of Lanes: _____ ÿ L-shaped pool

Pool 2: Length _____ ÿ Yards ÿ Meters Width: _____ ÿ Yards ÿ Meters ÿ Indoor ÿ Outdoor

# of Lanes: _____ # of Lanes: _____ ÿ L-shaped pool

Pool 3: Length _____ ÿ Yards ÿ Meters Width: _____ ÿ Yards ÿ Meters ÿ Indoor ÿ Outdoor

# of Lanes: _____ # of Lanes: _____ ÿ L-shaped pool

Pool 4: Length _____ ÿ Yards ÿ Meters Width: _____ ÿ Yards ÿ Meters ÿ Indoor ÿ Outdoor

# of Lanes: _____ # of Lanes: ____

ÿ L-shaped po

FIND-A-CLUB CONTACT (To register as a club, a Find-a-Club Contact must be listed. Information will appear on the Find-A-Club page of USA Swimming’s Web site.)

FIND-A-CLUB CONTACT:

PHONE: EMAIL:______

Club Contact (This person will receive USA Swimming mailings and be responsible for athlete registration.)

CLUB CONTACT ______

POSITION ______

MAILING ADDRESS ______

CITY ______STATE ______ZIP ______

OFFICE PHONE ______HOME PHONE ______

FAX ______MOBILE PHONE ______

E-MAIL ADDRESS ______

LEARN TO SWIM PROGRAM

Does the club or coach own and operate a Learn to Swim Program? o Yes o No

If yes, is the club a current Make a Splash Local Partner? o Yes o No

If no, is the club associated with a Learn to Swim Program? o Yes o No

Coach (All clubs must have at least one properly registered coach to register as a USA Swimming club. Club’s coach of record must be at least 18 years old.)

HEAD COACH ______DATE OF BIRTH ______

MAILING ADDRESS ______

CITY ______STATE ______ZIP ______

OFFICE PHONE ______HOME PHONE ______

FAX ______MOBILE PHONE ______

E-MAIL ADDRESS ______

I hereby give Gulf Swimming permission to use my name, address, and phone numbers (above) for publication in the Gulf Swimming Handbook and the Gulf Swimming web page.

Head Coach (Signature) ______

Club Treasurer

TREASURER ______

MAILING ADDRESS ______

CITY ______STATE ______ZIP ______

OFFICE PHONE ______HOME PHONE ______

FAX ______MOBILE PHONE ______

E-MAIL ADDRESS ______

Club Entries/Records Contact

ENTRIES/RECORDS CONTACT ______

MAILING ADDRESS ______

CITY ______STATE ______ZIP ______

OFFICE PHONE ______HOME PHONE ______

FAX ______MOBILE PHONE ______

E-MAIL ADDRESS ______

I hereby give Gulf Swimming permission to use my name, address, and phone numbers (above) for publication in the Gulf Swimming Handbook and the Gulf Swimming web page.

Entries/Records Contact (Signature) ______

Club Nominees to the Gulf Swimming House of Delegates (The number of representatives to the Gulf Swimming House of Delegates and the votes to which they are entitled is governed by Section 604.1.1 of the Gulf Swimming Bylaws. All representatives to the House of Delegates must be registered as non-athlete members of USA Swimming.)

TEAM REPRESENTATIVE ______

MAILING ADDRESS ______

CITY ______STATE ______ZIP ______

OFFICE PHONE ______HOME PHONE ______

FAX ______MOBILE PHONE ______

E-MAIL ADDRESS ______

I hereby give Gulf Swimming permission to use my name, address, and phone numbers (above) for publication in the Gulf Swimming Handbook and the Gulf Swimming web page.

Team Representative (Signature) ______

ALTERNATE REPRESENTATIVE ______

MAILING ADDRESS ______

CITY ______STATE ______ZIP ______

OFFICE PHONE ______HOME PHONE ______

FAX ______MOBILE PHONE ______

E-MAIL ADDRESS ______

I hereby give Gulf Swimming permission to use my name, address, and phone numbers (above) for publication in the Gulf Swimming Handbook and the Gulf Swimming web page.

Alternate Representative (Signature) ______

Club President ______ ______

MAILING ADDRESS ______

CITY ______STATE ______ZIP ______

OFFICE PHONE ______HOME PHONE ______

FAX ______MOBILE PHONE ______

E-MAIL ADDRESS ______

I hereby give Gulf Swimming permission to use my name, address, and phone numbers (above) for publication in the Gulf Swimming Handbook and the Gulf Swimming web page.

Club President (Signature) ______

PRIMARY ORGANIZATIONAL AFFILIATION, WHO OWNS THE CLUB, CLUB TAX LISTING (To register as a club, a selection must be made for Primary Organizational Affiliation, Who Owns the Club and Club Tax Listing.)

o Check if registered last year and there are no changes to the Primary Organizational Affiliation, Who Owns the Club and Club Tax Listing that were listed last year.

PRIMARY ORGANIZATIONAL AFFILIATION

(Please note the club’s primary relationship/affiliation with

any one of the following organizations. Choose one only.)

o  Not Applicable

o  Boys & Girls Club

o  College/University

o  Country Club

o  Health & Fitness Club

o  Hospital

o  Jewish Community Center

o  Park & Recreation Department

o  Private School

o  Public School/District

o  Summer Club or Home Owner’s Association

o  YMCA

o  YWCA

o  Other

WHO OWNS THE CLUB

o  Coach Owned

o  Boys & Girls Club

o  College/University

o  Country Club

o  Health & Fitness Club

o  Hospital

o  Jewish Community Center

o  Non-Profit Corporation (Parent Board)

o  Park & Recreation Department

o  Private School

o  Public School/District

o  Summer Club or Home Owner’s Association

o  YMCA

o  YWCA

o  Other

CLUB TAX LISTING

(Please list the club’s main tax listing and not the parent’s/booster organization if it is a separate entity.)

o  Sole Proprietor

o  Partnership

o  LLC

o  Sub-S Corporation

o  Other For-Profit Corporation

o  501(c)3 Non-Profit Corporation

o  Other 501(c) Non-Profit

o  Other Non-Profit Corporation

o  Does Not Apply

Send completed application, team check for $250.00, safety information form, and safety map to:

Annette Leach

46155 Hwy 6 & 24

Glenwood Springs, CO 81601

Do not write below this line

For GULF SWIMMING use only

Coach’s certification and team’s representatives to the House of Delegates

memberships verified by ______Date ______

Team bylaws (new applications only) received by ______Date ______

Safety information form received by ______Date ______

Safety map received by ______Date ______

Annual dues: Team check # ______Date ______

All fines from previous season cleared ______Date ______

Club application for 2017 approved by ______Date ______