Denise - Notification Of Membership

Notification of Membership in USA Swimming

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First Name *

Last Name *

USA Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

I am a citizen of *

Date of birth (mm/dd/yyyy) *

I am now or have been a member of the following FINA Federation: *

The date of my last competition as a member of that Federation was (athlete must provide written confirmation from the federation as to the last date of competition in the federation):

Club Competition

Date: +

National/International Competition

Date: +

I make application for status as (select one): *

Attached

Unattached

Local Swimming Committee *

LSC Map

If attached, name of USA Swimming Member Club

Please upload any supporting documents.

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Name of Parent / Guardian (if athlete is under the age of 18)

Date of submission: +

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Today's Date: * +

Click the SUBMIT button when you have completed the form