Open Water Swim Program Registration Form

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Last Name


First Name


DOB


Address

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Phone Number



Email Address


For insurance purposes, in order to participate, you must be a member of U.S.
Masters Swimming. To join USMS please visit: http://tinyurl.com/hkdwhjd

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USMS Membership Number



EMERGENCY CONTACT:

Name:______________________________________ Phone Number:______________________________

Payment is due in full before first session and is non-refundable.
Checks payable to “Swymnut Masters” or pay with cash/credit card at the
first session. Cost is $260 ($220 for members of Swymnut Masters).
OFFICE USE ONLY:

Check _____ Cash ______ Charge _____

Processed By:

Date Processed:

Total Paid: $_______________