Individual Entry Form

Name*

FirstLast

Address*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Phone*

Email*

Age*

Date of Birth*

Sex*

Male
Female

USMS Membership Number*

All Swim For Kid's Sake participants must either be members of USMS or purchase a one-day event membership for $15. Please indicate "one-event membership" if this is the case.

Event(s) Please Check All that Apply*

Will You Be Attending the Pre-Race Dinner on June 11, 2010?*

Yes
No
Yes, and I will be bringing a guest(s).

How many additional tickets will you be purchasing for the Pre-Race Dinner?

Admission to the Pre-Race Dinner is INCLUDED for all Swim For Kid's Sake participants. Additional tickets can be purchased for $18/person.

T-Shirt Size*

A t-shirt is INCLUDED for all Swim For Kid's Sake participants. Additional t-shirts can be purchased for $15 each.

Please describe your open water swimming history.*

How did you hear about the Swim For Kid's Sake?*

How has Riley Hospital for Children or Pediatric Low Grade Astrocytoma (PLGA) impacted your life or the life of someone you know?*

Will you be collecting additional donations to go toward children's charities?*

Yes
No

If Yes, what is your fundraising goal?

Additional Comments

Release and Hold Harmless Agreement

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. Finally, I specifically acknowledge that I am aware of all the risks inherent in open water swimming, and agree to assume those risks.

I Agree*