USA SWIMMING – 2016 CLUB APPLICATION

CLUB CODE: CLUB NAME:

NAME OF OWNER/BUSINESS/LEGAL ENTITY IF DIFFERENT FROM CLUB NAME:1.

2.

3.

CLUB SETTING: Rural Suburban Urban

PLEASE CHECK ONE:

4.

5.

□ NEW CLUB RENEWING CLUB NEW ORGANIZATION RENEWING ORGANIZATION

(Club is defined as a group with athletes and (Organization is defined as a group without athletes and coaches. No coaches. Insurance certificate will be issued.) insurance certificate will be issued. Seasonal clubs cannot be

organizations.) FIRST YEAR AS A USA SWIMMING CLUB:

NEAREST MAJOR CITY: CLUB WEB SITE:

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 employees who are required to be members of USA Swimming as required in the USA Swimming Rules & Regulations, Article 502.6.8.

Signature: Printed Name: Date:

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

RACING START CERTIFICATION

□ By checking this box and signing below, I formally acknowledge that this club complies with all Racing Start Certification requirements as stated in the USA Swimming Rules & Regulations, Article 103.2.2 and maintains records for its athlete members.

Head Coach Signature: Printed Name: Date:

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

CLUB/MARKETING CONTACT/REPRESENTATIVE:

POSITION (board president, owner, coach, etc.):

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE: BUSINESS: MOBILE:

FAX: EMAIL:

□ Check if registered last year and there are no changes to the Primary Organizational Affiliation, Who Owns the Club and Club Tax Listing that were listed last year.

PRIMARY ORGANIZATIONAL AFFILIATION(Please note the club’s primary relationship/affiliation with any one of the following organizations. Choose one only.)

□ Not Applicable□ Boys & Girls Club□ College/University□ Country Club□ Health & Fitness Club□ Hospital□ Jewish Community Center□ Park & Recreation Department□ Private School□ Public School/District□ Summer Club or Home Owner’s Association□ YMCA□ YWCA

□ Other

CLUB/MARKETING CONTACT/REPRESENTATIVE (This person will receive USA Swimming mailings and be responsible for distributing the information. Will also be eligible to vote at the MS House of Delegates Meeting(s))

PRIMARY ORGANIZATIONAL AFFILIATION, WHO OWNS THE CLUB, CLUB TAX LISTING (To register as a club, a selectionmust be made for Primary Organizational Affiliation, Who Owns the Club and Club Tax Listing.)

WHO OWNS THE CLUB

□ Coach Owned□ Boys & Girls Club□ College/University□ Country Club□ Health & Fitness Club□ Hospital□ Jewish Community Center□ Non-Profit Corporation (Parent Board)□ Park & Recreation Department□ Private School□ Public School/District□ Summer Club or Home Owner’s Association□ 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.)

□ 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

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.)

FIND-A-CLUB CONTACT:

PHONE: EMAIL:

REGISTRATION DATE AND TYPE

REGISTRATION DATE: (For LSC Office Use Only)

PLEASE CHECK ONE:□ YEAR-ROUND CLUB SEASON 1 CLUB SEASON 2 CLUB ORGANIZATION

HEAD COACH

COACH:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE: BUSINESS: MOBILE:

FAX: EMAIL:

CLUB PRESIDENT or PERSON RESPONSIBLE FOR OVERSIGHT OF CLUB

CLUB PRESIDENT:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE: BUSINESS: MOBILE:

FAX: EMAIL: □ Check if registered last year and there are no changes to the facilities that were listed last year.

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

FACILITY NAME:

ADDRESS:

CITY: POOLS AT THIS FACILITY:

STATE: ZIP:

Pool 1: Length: Yards Meters Width: Yards Meters Indoor Outdoor# of Lanes: # of Lanes: □ L-shaped pool

Pool 2: Length: Yards Meters Width: Yards Meters Indoor Outdoor# of Lanes: # of Lanes: □ L-shaped pool

FACILITY NAME:

ADDRESS:

CITY:

POOLS AT THIS FACILITY:

STATE: ZIP:

Pool 1: Length: Yards Meters Width: Yards Meters Indoor Outdoor# of Lanes: # of Lanes: □ L-shaped pool

Pool 2: Length: Yards Meters Width: Yards Meters Indoor Outdoor# of Lanes: # of Lanes: □ L-shaped pool

FACILITY NAME:

ADDRESS:

CITY: POOLS AT THIS FACILITY:

STATE: ZIP:

Pool 1: Length: Yards Meters Width: Yards Meters Indoor Outdoor# of Lanes: # of Lanes: □ L-shaped pool

Pool 2: Length: Yards Meters Width: Yards Meters Indoor Outdoor# of Lanes: # of Lanes: □ L-shaped pool

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

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, use separate sheet of paper and attach to application.)

CLUB MEMBERSHIP COORDINATOR (Responsible for arranging for USA Swimming registration of all athlete and non-athlete members in the club and sending them to the Michigan Swimming Office.)

CLUB MEMBERSHIP COORDINATOR:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE: BUSINESS: CELL:

FAX: EMAIL:

CLUB TREASURER (Elected / appointed by the club.)

CLUB TREASURER:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE: BUSINESS: CELL:

FAX: EMAIL:

CLUB MEET ENTRY COORDINATOR (Responsible for sending club’s meet entries to host clubs.)

CLUB MEET ENTRY COORDINATOR:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE: 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: ATHLETE DELEGATE (Named by the club & will have voting privileges at the House of Delegates Meeting.)

ATHLETE DELEGATE:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE: 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.

Clubs renewing with a postmark between December 1st and December 31st will incur a fee of$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 are paid.

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 the clubs.

Send this completed form to:MICHIGAN SWIMMING, Inc.

2245 Knollcrest Rochester Hills, MI 48309Dawn Gurley: dawn.gurley@miswim.org 248-997-6696

PAYMENT OPTIONS:

Online via ACH – must be set up with Michigan Swimming Office; see ACH Form

Check payable to “Michigan Swimming”

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