WESTERN ZONE DIVERSITY and INCLUSION SELECT CAMP
and DIVERSITY SUMMIT
June 16 - June 19, 2016
University of Utah Natatorium, Salt Lake City, Utah
Montana Swimming Athlete Application
General Information:
Purpose: Instill a vision of success and inspire athletes from under-represented populations to become leaders in the sport of swimming.
Goals: To empower athletes from ethnically under represented populations, those economically disadvantaged, and LGBT to:
1. Demonstrate the viability of inclusiveness in swimming within their local LSC
2. Achieve performance excellence at every level of the sport
3. Expound the benefits and value of participating in the sport of swimming
4. Be positive leaders and role models that others from socioeconomic backgrounds can emulate
5. To connect, network and promote the virtues of the sport of swimming through a comprehensive strategy involving the athletes, coaches and LSC Diversity Chairs in their own local LSC’s and throughout the Western Zone.
Site: University of Utah, Salt Lake City, Utah. The University of Utah is located in the foothills of the Wasatch Mountains in Salt Lake City. The Ute Natatorium features three pools: a six lane 25 yard training pool, an eight lane 25 yard competition pool and the newly refurbished 20x15 diving well. Participants will be housed on campus.
Dates: June 16 - June 19, 2016. Athletes and coaches will arrive Thursday late afternoon/ evening and depart Sunday morning. Summit participants will arrive Friday and depart Sunday morning.
Number of Attendees: 2 athletes from Montana Swimming will be selected to attend the camp.
MT Swim Application Deadline: Saturday April 2, 2016. All athlete applicants must submit a completed application and a short essay explaining what he/she hopes to learn by attending this camp.
Applications should be submitted to: Susan Huckeby at . (E-mail is preferred). Mailed applications may be sent to 2001 Aberdeen St., Butte, MT 59701. 406-723-4800.
Athlete Age: 13 -16 years of age as of June 16. (9-10th grades).
Funding: Montana Swimming will pay the $240 camp registration fee which includes on campus rooming, all meal costs per person, and local event ground transportation including transportation to and from the airport in Salt Lake City to the camp site.
Travel costs: Families of the athletes may submit in writing to be reimbursed up to $300 for travel to the MT Swimming Treasurer if the families had to pay for the travel costs and will be reimbursed no more than the costs or $300.00 whichever is less. Reimbursement can be submitted after completion of the camp and up to 3 months after the last day of camp and must include receipt for flight or if attended by car, mileage will be reimbursed at the government rate.
Athlete Qualifications: All athletes must be 2016 registered athlete members of Montana Swimming.
· Preferred Qualifications: Athletes must have an "A" time in one or more events in any course either as a 13-14 or as a 15-16 year old athlete. Designate the time standard achieved and age on the application.
· Secondary Qualifications: If there are no athletes apply who meet the preferred qualifications then MT Swimming may select athletes who have qualified in at least one individual event at the MT Swim SC State or LC State Championships.
· In the event that there are no qualifying swimmers, MT Swim can elect to send two athletes (and alternates if accepted) of its choice.
· Additional Information: If an athlete has attended a previous Western Zone Diversity and Inclusion Select Camp or a USA Swimming National Diversity Select Camp, the athlete may not attend this Western Zone Diversity and Inclusion Select Camp. An athlete may attend only one Western Zone Diversity and Inclusion Select Camp.
MT Swimming Selection Process for Athletes: MT Swimming will select two athletes based on the applications submitted using the stated criteria. Athletes will be notified by no later than April 9 and must accept by no later than April 11. Two alternates will also be selected.
Camp Schedule: The three day camp program will include a combination of pool training, motivational and education sessions, networking and strategic planning sessions for members of each LSC, and team building activities. The campers will also participate in a local outreach event. An athlete social activity is also planned.
Camp Staff: The camp staff includes head coach, and assistant coach to be selected in April by USA Swimming as well as a national athlete along with the camp oversight committee.
Application: Posted on the Montana Swimming website or contact Susan Huckeby, MT Swimming Diversity and Inclusion Chair.
Questions: Please contact Susan Huckeby or 406-723-4800.
Western Zone Diversity and Inclusion Select Camp and Diversity Summit
Montana Swimming Athlete Application
June 16- June 19, 2016
University of Utah
Salt Lake City, Utah
ATHLETE APPLICATIONS MUST BE RETURNED BY:
Saturday April 2, 2016. E-mail to Susan Huckeby at
Athlete’s Name: ______
Street Address: ______
City/State/Zip: ______
Athlete’s Phone number: cell: (____)______home: (____)______
Athlete’s Email Address: ______
USA Swimming ID Number: ______
Date of Birth: ____/ ____/ ______Male ___ Female
Club Name: ______Club Abbreviation: ______
Coach Name:______E-mail: ______
Parent Names: (Father) ______
(Mother) ______
Parent contact Email Address: ______
Parent contact phone number: cell:______home:______
T-shirt size: _____ Small; _____Medium; _____Large; _____XLarge (check one) -- Adult sizes
Western Zone Diversity Select Camp Eligibility:
Any swimmer who represents an ethnically under-represented population that is less than 20% of the current USA Swimming membership as well as outreach and LGBT athletes. You may check more than one:
___ African American ___ Hispanic or Latino ___ Native Hawaiian or other Pacific Islander
___ Native Alaskan ___ Asian ___ Native American ___Outreach ___ LGBT
___ Other Ethnicity ______(List)
Essay: Submit a short written essay explaining what you hope to learn at the camp. Submit the essay with the application.
MUST READ AND INITIAL ALL STATEMENTS OR APPLICATION WILL NOT BE CONSIDERED
__ I will be physically ready for training when I arrive at camp.
__ I understand that I must meet the ethnicity/outreach/LGBT eligibility (above) to apply for this camp.
__ I understand that I must meet the selection eligibility requirements and the qualifying time standards to apply for this camp.
__ I understand the additional camp details will be provided to me upon my acceptance.
__ I understand that additional paperwork that I receive MUST be returned to the MT Swimming and Western Zone Diversity Select Camp Oversight Committee on or before their published deadlines.
__ I have listed at my qualifying times for the camp on my application. If I have not achieved the preferred qualification, I have listed the secondary qualifications that I have achieved on my application.
__ I understand funding for this camp will come from MT Swimming as listed in the camp application. It includes $240 for camp registration and travel costs as specified above.
__ I will follow all the USA Swimming rules, camp rules, and the Montana Swimming rules including code of conduct and safe sport. Failure to follow the rules may result in the athlete being returned home from camp at the family's expense and the athlete may be subject to other disciplinary action.
__ I am returning this application to Susan Huckeby for submission by April 2, 2016.
__ I have not attended a previous Western Zone Diversity and Inclusion Select Camp or a USA Swimming National Diversity Select Camp.
Use this section to list your camp qualifying time:
Event Qualifying Time Meet Where Date/Location USA Swimming
(List SCY or LCM) Time Std Age Time Was Achieved of Meet Power Points
Use this section to list your other best events and times even if you do not have a camp qualifying time
standard in that event:
Event Qualifying Time Meet Where Date/Location USA Swimming
(List SCY or LCM) Time Std Age Time Was Achieved of Meet Power Points
List your IMX Score for the current season: ______
(Find the IMX Score on your own MY USA Swimming page at www.usaswimming.org.
Find more information about IMX in the Times/Time Standards section on the USA Swimming website.)
Signatures below testify to the eligibility of the athlete:
Parent/Guardian Signature: ______Date______
Athlete Signature: ______Date______
Coach of Record Signature: ______Date______
2016 Western Zone Diversity and Inclusion Select Camp
University of Utah, Salt Lake City, Utah
June 16 - June 19, 2016
Medical Authorization
Athlete Name: ______LSC: Montana
I consent to medical care for my minor child, including routine diagnostic procedures and medical, dental, and/or surgical treatment by a physician, if needed during the 2016 Western Zone Diversity and Inclusion Select Camp. I give consent to the camp staff to obtain said medical care if needed.
______
Parent or Legal Guardian Signature Printed Name Date
______
Swimmer's Signature Date Swimmer Date of Birth
List any medical conditions: ______
______
List any allergies including medication, food, and over the counter medications: ______
______
List any medications that must be administered: ______
______
Any special food requirements: ______
______
Please include telephone numbers where a parent, relative or guardian may be reached in case of an emergency.
Contact Name______Phone: (_____) ______cell/home/work - day or night
Phone: (_____) ______cell/home - day or night Relationship______
Contact Name______Phone: (_____) ______cell/home/work - day or night
Phone: (_____) ______cell/home - day or night Relationship______
Insurance Information:
Insurance Company: ______
Policy Number: ______
Phone Number: ______
Address: ______
City, State, Zip Code: ______
Montana Swimming Code of Conduct
2016 Western Zone Diversity and Inclusion Select Camp
June 16-19, 2016 Salt Lake City, Utah
I, (athlete/staff member) ______, and (parent) ______as a member of Montana Swimming understand and will comply with the following as approved by the Montana Swimming Board of Directors:
1. To follow all directions given by coaches, chaperones, and camp staff.
2. The manner by which one behaves will present a positive image of Montana Swimming and will provide an atmosphere to meet the camp, educational, or training objectives for all. I recognize that my conduct is my responsibility, and failure to abide by appropriate conduct could lead to disciplinary action.
3. Proper respect, sportsmanship, and courtesy toward coaches, camp staff, administrators, trainers, educators, chaperones, and the public will be displayed at all times as representatives of Montana Swimming.
4. The possession or use of alcohol, tobacco products, or controlled substances by athletes is prohibited throughout the designated duration of the trip.
5. Swimmers of the opposite gender are not to be in each other’s rooms. Conversations, etc. will take place in a common area as identified by the camp staff.
6. Curfews will be established by the camp staff and adhered to during the camp Curfew violations could result in disciplinary action as listed below.
7. Attendance is required at all camp functions which include, but are not limited to: meetings, practices, outreach activities, meals, and other camp activities unless otherwise excused or instructed by the camp staff.
8. Campers will not leave the camp group for any reason without having prior permission by the coaching or camp staff. This includes but is not limited to while at the campus, lodging and dining, pool venue, van or bus travel, or other camp identified activities.
9. Additional guidelines may be established as needed to maintain the safety and well-being of the camp members and will be adhered to during the camp.
We, (swimmer and parent) understand that failure to comply with the Montana Swimming Code of Conduct, as set forth in this document or additions, as necessary, for the safety and well-being of the team members, may result in disciplinary action, which may include but is not limited to the following:
1. Dismissal from the camp and return home at my own expense.
2. Disqualification from future Team Montana Swimming sponsored activities, ie: clinics, AAA camps or other MT sponsored meets,
I may appeal any disciplinary action in accordance with part four of the U.S. Swimming Rules and Regulations and Article 610 of the Montana Swimming Bylaws.
Signature: ______Signature: ______
(Athlete) Date (Parent or Legal Guardian) Date
Complete, sign, and submit the application and essay by April 2, 2016 to Susan Huckeby at .
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