Naples Island Swim Online Entry

First Name:       MI:       Last Name:

Address:

City:       State/Province: select Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland and Labrador New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Yukon       ZIP/Postal Code:

Telephone: (include area code)  -  - 

email address: (i.e. swimmer@lbgrunions.com)    

Age (as of September 14, 2008):       Gender:   select Female Male

Club Abbreviation:          USMS Number:  

Race:   select 3 mile 1 mile       T-shirt Size:   select Small Medium Large X-Large XX-Large

Emergency Contact:

Emergency Contact Telephone: (include area code)  -  - 

LIABILITY RELEASE: I, the 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 of 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 CAUSED BY THE NEGLIGENCE, ACTIVE OR PASSIVE, OF THE FOLLOWING: UNITED STATES MASTERS SWIMMING, INC., THE LOCAL MASTERS SWIMMING COMMITTEES, LONG BEACH AQUATICS ASSOCIATION, LONG BEACH GRUNION SWIM TEAM, THE CITY OF LONG BEACH, HOST FACILITIES, MEET SPONSORS, MEET COMMITTEES, OR ANY INDIVIDUALS OFFICIATING AT THE MEET 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 I agree to assume these risks.

Please indicate that you have read, understood and agree to the above LIABILITY RELEASE     No Yes