Masters
Richfield Swim Club
Swimmer Information
Name(s):______________________________________________________________________
Street Address:_________________________________________________________________
City: ________________________State: _____ Zip:_________ Email: ____________________
Home Phone:___________________________
Work Phone: _________________Ext:_______
Male/Female:_________ Birthdate: ______________Present Age:______
Emergency Contact Name and Number _____________________________________________________
To participate on the Masters Swim Team you must be registered with USA Swimming
OR United States Masters Swimming. You must complete either registration form and pay the appropriate fee.Are you currently USA Registered? __________ If yes, with what team?_________________________
Are you currently registered with USMS? _________Registration # _____________________________
If you answered NO to both questions, you MUST pick one in order to SWIM!
Fee Structure
$30/month
Payments can handed to the coach or sent to:
Richfield Swim Club
6640 Lyndale Ave. S. #110-301
Richfield, MN 55423
In consideration of the opportunity to participate in the Swimming program, I, on behalf of myself, my agents, heirs, next-of-kin, hereby release and hold harmless the Richfield Swim Club and it’s respective agents, employees, and representatives from any responsibility or liability for personal injury, including death, or damage to or loss of property, that I may incur due to the negligence of the club, my own negligence or accidents that occur while I am participating in this program.
Waiver: I have read and understand all terms
Athlete Signature ______________________________ Date ________________