Name of Owner/Business/Legal Entity If Different from Club Name

USA SWIMMING – 2016 CLUB APPLICATION

CLUBCODE:CLUBNAME:

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

3. CLUBSETTING:RuralSuburbanUrban

PLEASE CHECK ONE:

□NEWCLUBRENEWINGCLUBNEWORGANIZATIONRENEWINGORGANIZATION

(Clubisdefinedasagroupwithathletesand(Organizationisdefinedasagroupwithoutathletesandcoaches.Nocoaches. Insurance certificate willbeissued.) insurancecertificatewillbeissued.Seasonalclubscannotbe

organizations.) FIRSTYEARASAUSASWIMMINGCLUB:

NEARESTMAJORCITY:CLUB WEBSITE:

PRE-EMPLOYMENT SCREENING

□By checking this box and signing below, I formally acknowledge that this club is conducting a pre-employment screening on all new employeeswhoarerequiredtobemembersofUSASwimmingasrequiredintheUSASwimmingRulesRegulations,Article502.6.8.

Signature:PrintedName:Date:

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

RACINGSTARTCERTIFICATION

□By checking this box and signing below, I formally acknowledge that this club complies with all Racing Start Certification requirementsasstatedintheUSASwimmingRulesRegulations,Article103.2.2andmaintainsrecordsforitsathletemembers.

HeadCoachSignature:

PrintedName:

Date:

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

CLUB/MARKETING CONTACT/REPRESENTATIVE:

POSITION(boardpresident,owner,coach,etc.): ADDRESS:

CITY:

STATE:

ZIP:

HOMEPHONE:

BUSINESS:

MOBILE:

FAX:EMAIL:

□CheckifregisteredlastyearandtherearenochangestothePrimaryOrganizationalAffiliation,WhoOwnstheClubandClubTax Listingthatwerelistedlastyear.

PRIMARY ORGANIZATIONAL AFFILIATION

(Please note the club’s primary relationship/affiliation with anyoneofthefollowingorganizations.Chooseoneonly.)

□NotApplicable

□BoysGirlsClub

□College/University

□CountryClub

□HealthFitnessClub

□Hospital

□JewishCommunityCenter

□ParkRecreationDepartment

□PrivateSchool

□PublicSchool/District

□SummerCluborHomeOwner’sAssociation

□YMCA

□YWCA

□Other

WHO OWNS THE CLUB

□CoachOwned

□BoysGirlsClub

□College/University

□CountryClub

□HealthFitnessClub

□Hospital

□JewishCommunityCenter

□Non-ProfitCorporation(ParentBoard)

□ParkRecreationDepartment

□PrivateSchool

□PublicSchool/District

□SummerCluborHomeOwner’sAssociation

□YMCA

□YWCA

□Other

Continued on back…..

CLUB TAX LISTING

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

□SoleProprietor

□Partnership

□LLC

□Sub-SCorporation

□OtherFor-ProfitCorporation

□501(c)3Non-ProfitCorporation

□Other501(c)Non-Profit

□OtherNon-ProfitCorporation

□Does NotApply

FIND-A-CLUB CONTACT:

PHONE:EMAIL:

REGISTRATIONDATEANDTYPE

REGISTRATIONDATE:(For LSC Office UseOnly)

PLEASE CHECK ONE:

□YEAR-ROUNDCLUB SEASON1CLUB SEASON2CLUBORGANIZATION

HEADCOACHCOACH: ADDRESS:

CITY:

STATE:

ZIP:

HOMEPHONE:

BUSINESS:

MOBILE:

FAX:EMAIL:

CLUBPRESIDENTorPERSONRESPONSIBLEFOROVERSIGHTOFCLUBCLUBPRESIDENT: ADDRESS:

CITY:

STATE:

ZIP:

HOMEPHONE:

BUSINESS:

MOBILE:

FAX:EMAIL:

□Checkifregisteredlastyearandtherearenochangestothefacilitiesthatwerelistedlastyear.

If a facility is no longer in use by the club, list the facility name and the word “Delete” (example: Nathan Natatorium – Delete)

FACILITYNAME:

ADDRESS:

CITY: POOLSATTHISFACILITY:

STATE:

ZIP:

Pool1: Length: YardsMetersWidth: YardsMeters Indoor Outdoor

# ofLanes:

□L-shapedpool

Pool2: Length: YardsMetersWidth: YardsMeters Indoor Outdoor

# ofLanes:

□L-shapedpool

FACILITYNAME:

ADDRESS:

CITY: POOLSATTHISFACILITY:

STATE:

ZIP:

Pool1: Length: YardsMetersWidth: YardsMeters Indoor Outdoor

# ofLanes:

□L-shapedpool

Pool2: Length: YardsMetersWidth: YardsMeters Indoor Outdoor

# ofLanes:

□L-shapedpool

FACILITYNAME:

ADDRESS:

CITY: POOLSATTHISFACILITY:

STATE:

ZIP:

Pool1: Length: YardsMetersWidth: YardsMeters Indoor Outdoor

# ofLanes:

□L-shapedpool

Pool2: Length: YardsMetersWidth: YardsMeters Indoor Outdoor

# ofLanes:

□L-shapedpool

If any of the above information changes, please notify your LSC Registration Chair.

CLUBMEMBERSHIPCOORDINATOR: ADDRESS:

CITY:

STATE:

ZIP:

HOMEPHONE:

BUSINESS:

CELL:

FAX:EMAIL:

CLUBTREASURER(Elected/appointedbytheclub.)CLUBTREASURER: ADDRESS:

CITY:

STATE:

ZIP:

HOMEPHONE:

BUSINESS:

CELL:

FAX:EMAIL:

CLUBMEETENTRYCOORDINATOR(Responsibleforsendingclub’smeetentriestohostclubs.)CLUBMEETENTRYCOORDINATOR: ADDRESS:

CITY:

STATE:

ZIP:

HOMEPHONE:

BUSINESS:

CELL:

FAX:EMAIL:

ATHLETE REPRESENTATION AT THE HOUSE OF DELEGATES: By USA Swimming mandate,

20% of the members eligible to vote at the LSC House of Delegates meeting must be athletes. Michigan Swimming has resolved that when clubs register each year with MS they may designate an athlete representative from their club. MS will notify those athletes of the time and place for the House of Delegates meeting and invite them to participate as voting members. Please designate the ATHLETE DELEGATE from your club in the space below:

ATHLETEDELEGATE(NamedbytheclubwillhavevotingprivilegesattheHouseofDelegatesMeeting.)ATHLETEDELEGATE: ADDRESS:

CITY:

STATE:

ZIP:

HOMEPHONE:CELL: FAX: EMAIL:

2016 Club memberships are valid September 1, 2015 with expiration December 31, 2016

Michigan Swimming follows a sliding scale for club renewals as listed below:

Clubs renewing their club membership prior to November 30th will be charged $125.00.
ClubsrenewingwithapostmarkbetweenDecember1st andDecember31st willincurafeeof

$150.00

Renewals postmarked after January 1st will be charged$300.00.
Registration or renewal for the head coach with all requirements current must accompany (or be completed prior to) the club renewal in order to avoid the increased charges.

Please note the following:

Clubs not renewed by 1/1/2016 may not register additional athletes or non-athletes until 2016 club dues arepaid.
Athletes registered for 2016 with a club that has not renewed by 1/1/2016 will be transferred to an UNATTACHED status and clubs will be charged $5 per athlete for reattaching.
Clubs hosting meets during the 2016 short course season must renew their 2016 club membership before the meet information will be posted on the MS website and distributed to theclubs.
Send this completed formto:

MICHIGAN SWIMMING, Inc.

2245 Knollcrest Rochester Hills, MI 48309

Dawn Gurley: 248-997-6696

PAYMENT OPTIONS:

Online via ACH – must be set up with Michigan Swimming Office; see ACH Form
Check payable to “MichiganSwimming”

If any of the above information changes, please notify your LSC Registration Chair.