Entry Form
Please print clearly and completely with blue
or black ink -Incomplete or illegible entries will be rejected
Name Last:
__________________________First:______________________________.
Address:_______________________________________________________________.
City:
________________________________State:_________________Zip:_________.
Birth Date:___________________. Age on Race
Day_______________Sex: (Male) (Female)
Phone: Home: (_____)__________________ Office:
(____)______________________.
Email:_________________________________________________________________.
Results will be posted online to save mailing
costs. Should you want a hardcopy of the results mailed please check here____
(5k only).
Authorization and Event Promotion
:I
agree to be filmed and photographed by the official and authorized
photographers of this event under the conditions authorized by the Host and
Meet Directors, and give the event organizers (host and meet director) the
right to use my name, picture, likeness, and biographical information before,
during and after the period of my participation in this event to promote the
event in which I compete or to promote the success of the team on which I
competed. I will not promote third party sponsors, causes, or charities unless
pre-approved by the Meet Director I
also understand that refunds will not
be given under any circumstances
USMS
SWIMMERS -REMEMBER TO ATTACH A COPY OF
YOUR REGISTRATION CARD
USMS Release:
'I, the undersigned participant, intending to be legally bound, hereby
certify that I am physically fit and have not been otherwise informed by a
physician. I acknowledge that I am aware of all the risks inherent in Masters
Swimming (training and competition), including possible permanent disability or
death, and agree to assume all of those risks. AS A CONDITION OF MY
PARTICIPATION IN THE MASTERS SWIMMING PROGRAM OR ANY ACTIVITIES INCIDENT
THERETO, I HEREBY WAIVE ANY AND ALL RIGHTS TO CLAIMS FOR LOSS OR DAMAGES,
INCLUDING ALL CLAIMS FOR LOSS OR DAMAGES CAUSED BY THE NEGLIGENCE, ACTIVE OR
PASSIVE, OF THE FOLLOWING: UNITED STATES MASTERS SWIMMING, INC., THE LOCAL
MASTERS SWIMMING COMMITTEES, THE CLUBS, HOST FACILITIES, MEET SPONSORS, MEET
COMMITTEES, OR ANY INDIVIDUALS OFFICIATING AT THE MEETS OR SUPERVISING SUCH ACTIVITIES.
In addition, I agree to abide by and be governed by the rules of
USMS." I also specifically
acknowledge that I am aware of all the risks inherent in open water swimming
and agree to assume those risks.
USMS Swimmers
signature_______________________________________________DATE:_______________________.
Parents Signature (for swimmers 18 & under
in one mile swim)__________________________DATE:______________.
USMS 5k National
Championships..................................$25........__________.
T-Shirt Size -circle one - MEDIUM
LARGE X-LARGEincluded.
Late entry after April 20th and on Race
Day.....................$40........__________.
USMS
Clinic.....................................................................$25........__________.
Late entry after April 20th and event day..........................$35........__________.
The Victor Hollywood
Mile..................................................$20
.......__________.
Late entry after April 20th and on Race
Day.........................$30........__________.
TOTAL:__________.
Entry fee should be made payable and mailed to: (if you would like a confirmation please
include a SASE)
Aqua Moon Adventures
PO Box 9448
Coral Springs, Florida 33075
