Athlete Application

CENTRAL ZONE Multi-cultural Swim Meet June 12-14, 2015 Brownsburg, IN Athlete Application

APPLICATION DEADLINE: MAY 15, 2015 RETURN APPLICATION TO: Betty Kooy, Midwestern Swimming, 1429 N Webster Ave, Hastings NE 68901

Athlete’s Name: ______

Street Address: ______

City/State/Zip: ______

Phone: ( ) ______

Athlete’s Email Address: ______

USA Swimming Number: ______

Date of Birth: ____/ ____/ ______Male ___ Female

Club Name: ______

Parent Names: (Father) ______

(Mother) ______

Parent contact Email Address: ______

Central Zone Multi-cultural Meet Opportunity: Any swimmer who represents an ethnically under-represented population that is less than 20% of the current USA Swimming membership OR current Out-Reach athletes - You may check more than one:

__ African American __ Native American __ Hispanic __ Asian or Pacific Islander

__ Out-Reach Athlete __ Other (describe) ______

Have you participated in past MWS Supported meet/s? (All-Star, Sectional, Zone or Jr. Nationals)? ______(Yes/No) If Yes to MWS supported meets, please list the meets and year/s ______(Note: Priority will be given to athletes who have not had the past opportunity to participate in MWS supported meets.)

Signatures below testify to the eligibility of the athlete:

Parent/Guardian Signature: ______

Coach of record Signature: ______MUST READ AND CHECK ALL OR APPLICATION WILL NOT BE CONSIDERED

__ I understand that I must meet the ethnicity or out-reach athlete eligibility (above) to apply for this meet.

__ I understand the additional meet details will be provided to me upon my acceptance.

__ I understand that additional paperwork that I receive MUST be returned to the Midwestern Swimming Multi-

cultural Meet Committee on or before their published deadlines. (Midwestern Office)

__ I understand funding for this meet will come from Midwestern Swimming for transportation, room and entry fees

provided for me at the meet.

__ I understand that I will be responsible for the cost of food traveling to and from the meet and while at the meet.

__ I am returning this application to Betty Kooy, Midwestern Swimming for submission by their published deadline of

May 15, 2013.

______(ATHLETE’S SIGNATURE) (DATE)

______(COACH’S SIGNATURE) (DATE)