2017 Apprentice Official Application

USA SWIMMING

2017 APPRENTICE OFFICIAL APPLICATION

LSC: Allegheny Mountain (AM)

INITIAL TRAINING SESSION DATE: (Required)

MEET NAME & LOCATION: (Required)

PLEASE PRINT LEGIBLY l COMPLETE ALL INFORMATION TO ENSURE THAT CONTACT INFORMATION IS CORRECT AND UP TO DATE:

LAST NAME LEGAL FIRST NAME MIDDLE NAME

Have you ever been a member of USA Swimming under a different last name? If yes, please provide that name:

Previously registered with USA Swimming? o Yes o No If registered in a different LSC, which LSC:

PREFERRED NAME DATE OF BIRTH (MO/DAY/YR) SEX (M/F) CLUB CODE CLUB NAME

(Bill, Beth, Scooter, Liz, Bobby) If not affiliated with a club, enter “Unattached”

MAILING ADDRESS

CITY STATE ZIP CODE

AREA CODE TELEPHONE NO. AREA CODE TELEPHONE NO. E-MAIL ADDRESS

HOME MOBILE

LSC Registrar Contact Info: LSC Officials Chair Contact Info:

Laura Hartman Scott Pauley

Pittsburgh, PA 15220 412-414-5134

Instructions:

1.  This form must be submitted to the LSC Registrar and Officials Chair by the Tuesday prior to beginning you shadowing.

2.  Initial training session date/meet/location must be completed when submitting form

3.  E-mail completed form to and cc .

4.  After your application is processed you will be notified. At that time you must complete the Athlete Protection Training Course. https://www.usaswimming.org/DesktopDefault.aspx?TabId=2193&Alias=Rainbow&Lang=en.

5.  Within 60 days of your initial training date – you must complete the USA Swimming Background Check and become a fully registered non-athlete member of USA Swimming. You can still continue your training if not complete, but after 60 days you will not be permitted on deck without being registered.

Please direct questions to Laura Hartman (Registration Coordinator or Scott Pauley (Officials Chair)