CLUB MEMBERSHIP APPLICATION
USA Swimming ~ Minnesota Swimming
Club Application Directions for Completion and Submission:
Download this form to your desktop or a folder. Do NOT change or un-restrict the formatting. Put your cursor on the request form and click. It should go to the first item to be completed (or start by clicking on one of the boxes at the top). Continue to tab through the form to complete all the requested information. Save your information. Do NOT put this form in .pdf. Email the form as a WORD attachment (original format) to MSI ()
Check One: New Membership / Renewal / Club Update
Check One: Regular Membership / Seasonal Membership / Organizational Membership
Regular membership is for one calendar year expiring on 12/31.
Seasonal membership is for a specified 5 month period as designated yearly.
CLUB NAME:The name by which you wish to be identified / CLUB CODE:
Club’s 1-4 Character Club Abbreviation
CLUB WEBSITE:
CLUB E-MAIL ADDRESS: (same as club contact)
Indicate below the city/state your club should be listed under on USA Swimming website club search (limit 2).
CITY/STATE (1): / CITY/STATE (2):
DISCLAIMER: Information on this application may be used on the USA Swimming club Search website,
including the phone number and email address of the Club Contact.
CLUB CONTACT:Person who receives USA-S & MSI mailings/emails & is responsible for distributing information to club leadership.
Name:
Club Position: Board Member Registrar Coach Volunteer OwnerOther:
Address: City:State: Zip:
Home Phone: Business:Cell:
Fax: Email[required]:
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.[All information required]
Name:
Phone:Email:
HEAD COACH: Coach of Record-Must be a USA-S registered “Coach” member in year applying for membership. Clubs must have at least (1) registered coach to apply forMembership.
Name:
Address: City:State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
Coach Date of Birth: (mm/dd/yyyy): [required]
CLUB REGISTRAR: This individual is the ONLY person authorized & responsible to handle & process all registrations in the club and send them to MSI with proper form and fee in a manner prescribed by MSI policy.
NOTE:If multiple sites/teams swim under one club code, all membership cards, questions & issues for this club code will be directed to this person. This person is responsible for communicating to their sites & back to MSI.
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
CLUB TREASURER:
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
CLUB PRESIDENT:
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
CLUB ENTRIES COORDINATOR: Obtains meet information and enters club athletes intoswim meets.
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
ALTLETE LIAISON: Required Club Position[This information will not be published as public information.]
Serves as the Liaison between the club athletes and the MSI Athlete Committee.
Athete should preferably a minimum of 16 years old.
Name: Date of Birth: (MM/DD/YYYY)
Address: City: State: Zip:
Phone: Home Cell Email:
SAFETY COORDINATOR: Responsible for coordinating all safety matters within the club.
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
MINNESOTA SWIMMING DELEGATE: Required Club Position.Voting Delegate to MSI House of Delegates/ Bid Meeting.NA Membership required to vote.Serves asClub Representative to MSI Board Meetings.
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
ALTERNATE DELEGATE: Serves as voting delegate in absence of Delegate. Membership required to vote.
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
FACILITIES USED BY YOUR CLUB – LIST ALL FACILITIES (To register as a club, a facility must be listed. If additional space is needed to list facilities, copy/paste this page to a Word Document & attach to application.)
FACILITY NAME:
ADDRESS:
CITY: STATE: ZIP:
POOLS AT THIS FACILITY:
Pool 1:Length: Yards MetersWidth: Yards Meters Indoor Outdoor
# of Lanes:# of Lanes: L-shaped pool
Pool 2:Length: Yards MetersWidth: Yards Meters Indoor Outdoor
# of Lanes: # of Lanes: L-shaped pool
FACILITY NAME:
ADDRESS:
CITY: STATE: ZIP:
POOLS AT THIS FACILITY:
Pool 1:Length: Yards MetersWidth: Yards Meters Indoor Outdoor
# of Lanes:# of Lanes: L-shaped pool
Pool 2:Length: Yards MetersWidth: Yards Meters Indoor Outdoor
# of Lanes: # of Lanes: L-shaped pool
FACILITY NAME:
ADDRESS:
CITY: STATE: ZIP:
POOLS AT THIS FACILITY:
Pool 1:Length: Yards MetersWidth: Yards Meters Indoor Outdoor
# of Lanes:# of Lanes: L-shaped pool
Pool 2:Length: Yards MetersWidth: Yards Meters Indoor Outdoor
# of Lanes: # of Lanes: L-shaped pool
FACILITY NAME:
ADDRESS:
CITY: STATE: ZIP:
POOLS AT THIS FACILITY:
Pool 1:Length: Yards MetersWidth: Yards Meters Indoor Outdoor
# of Lanes:# of Lanes: L-shaped pool
Pool 2:Length: Yards MetersWidth: Yards Meters Indoor Outdoor
# of Lanes: # of Lanes: L-shaped pool
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.)
Choose one only per Category
PRIMARY ORGANIZATIONAL AFFILIATIONWHO OWNS THE CLUB
(Note the club’s primary relationship/affiliation with Coach Owned
any one of the following organizations.)Boys& Girls Club
Not ApplicableCollege/University
Boys & Girls ClubCountry Club
College/UniversityHealth & Fitness Club
Country ClubHospital
Health & Fitness ClubJewish Community Center
HospitalNon-Profit Corporation (Parent Board)
Jewish Community CenterPark & Recreation Department
Park & Recreation DepartmentPrivate School
Private SchoolPublic School/District
Public School/DistrictSummer club or Home Owner’s Association
Summer Club or Home Owner’s AssociationYMCA
YMCAYWCAYWCA
Other Other
CLUB TAX LISTING
(List the club’s main tax listing; not the parent’s or booster organization if it is a separate entity.)
Sole Proprietor
Partnership
LLC
Sub-S Corporation
Other For-Profit Corporation
501(c)3 Non-Profit Corporation
Other 501(c) Non-Profit
Other Non-Profit Corporation
Does Not Apply
Minnesota Swimming Use Only
Date Application received: Date Application approved:
Fee paid by club: Check # Date Check Received:
Additional Fee Due: Date Additional Fee Paid: Check #:
Club Membership
Assistant Coach Addendum
If additional assistant coaches are affiliated with your club, please use the single Asst Addendum page for additional pages add to club application, & email to MSI.
FULLCLUB NAME: CLUB CODE:
ASSISTANT COACH: (Must be current USA-S COACH member for coaching privileges on deck at practice & meets.)
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
ASSISTANT COACH: (Must be current USA-S COACH member for coaching privileges on deck at practice & meets
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
ASSISTANT COACH: (Must be current USA-S COACH member for coaching privileges on deck at practice & meets
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
ASSISTANT COACH: (Must be current USA-S COACH member for coaching privileges on deck at practice & meets
Name:
Address: City: State: Zip:
Home Phone: Business: Cell:
Fax: Email [required]:
Page 1 of 6 Minnesota Swimming Club Membership Application Revised 9-2011