Relay Entry Form

Swimmer #1

Name #1*

FirstLast

Phone*

Email*

Age*

Shirt Size*

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

Sex*

Male
Female

USMS Membership Number**

*Non-USMS members must purchase a one event membership

Will you be attending the Pre-Race dinner?*

Yes
No

Admission is INCLUDED for all Swim For Kid's Sake Participants. Additional tickets may be purchased for $18/person.

Swimmer #2

Name #2*

FirstLast

Phone*

Email*

Age

Shirt Size*

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

Sex*

Male
Female

USMS Membership Number**

*Non-USMS members must purchase a one event membership

Will you be attending the Pre-Race Dinner?*

Yes
No

Admission is INCLUDED for all Swim For Kid's Sake Participants. Additional tickets may be purchased for $18/person.

Swimmer #3

Name #3*

FirstLast

Phone*

Email*

Age*

Shirt Size*

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

Sex*

Male
Female

USMS Membership Number**

*Non-USMS members must purchase a one event membership

Will you be attending the Pre-Race Dinner?*

Yes
No

Admission is INCLUDED for all Swim For Kid's Sake Participants. Additional tickets may be purchased for $18/person.

Swimmer #4

Name #4*

FirstLast

Phone*

Email*

Age*

Shirt Size*

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

Sex*

Male
Female

USMS Membership Number**

*Non-USMS members must purchase a one event membership

Will you be attending the Pre-Race dinner?*

Yes
No

Admission is INCLUDED for all Swim For Kid's Sake Participants. Additional tickets may be purchased for $18/person.

Team Information

Team Name

Primary Team Contact

Address

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

Please provide an address for the designated team contact.

Which team members will be participating in the skills clinic?*

Swimmer 1
Swimmer 2
Swimmer 3
Swimmer 4

Please briefly 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?*

Fundraising Goal*

All relay teams are asked to participate in additional fundraising to benefit Riley Hospital for Children and the PLGA Foundation. Please indicate a fundraising goal for your team. Teams will be competing for an award for the most money raised.

Additional Comments

Please indicate if you would like to purchase additional t-shirts or additional tickets to the Pre-Race Dinner.

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 MYPARTICIPATION 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*