First Middle Last

Age: Birthdate:

Male/Female

Swimmer 2

First Middle Last

Age: Birthdate:

Male/Female

Swimmer 3

First Middle Last

Age: Birthdate:

Course Code: ___________

USA(USS) participantYMCA participant

USA(USS) participant

YMCA participant

Address:

Phone Number:

Parent/Guardian:

Work Number:

Emergency Contact:

Phone Number:

YMCA Member Number:

E-mail Address:

Program Fee: $170/First Swimmer

$150/Additional Family Members

(Discount is only available to swimmers of the same family.)

$170 for school swim team participants (late entry; early release)

First time swimmer? ___ Y ___ N

Amount Enclosed: $ ______________

Please return registration form with payment to Member Services.