MVS Non-Athlete Registration and Payment

Instructions

This form is used only for online registration and payment of Non-Athlete registrations with MVS.
All payments are processed using the secure PayPal website. If you do NOT want PayPal to process your online payment, DO NOT use this form. You will need to print and mail the MVS registration form along with a check for your membership fees.
The secure PayPal site accepts credit cards, debit cards and personal checks.
Once you have completed the form below, you will be sent automatically to the PayPal website to enter your payment information. No financial transactions are handled directly on the MVS site.
You will receive an email confirmation from PayPal once your payment has been approved.

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Your Registration

= Required Field

Last Name

Legal First Name

Middle Name

Preferred Name

Date of Birth

(mm-dd-yyyy)

Gender

Male Female

Club Name

Your Mailing Address

City

State

Zip Code

Home Phone

A/C	Number

Work Phone

A/C	Number	Ext

Fax Phone

A/C	Number

Cell Phone

A/C	Number

Email Address

Were you registered
with MVS last year?

Yes No

Have you ever been a
member of USA Swimming
under a different name?
If yes, under what name?

If registered in a different
LSC, which one?

Position

Full-Time Coach (primary income is from coaching)
Part-Time Coach (primary income NOT from coaching)
Official
Other

If registering as a coach,
your primary age group
(may be more than one)

10 & Under
11-12
13-14
15-16
17-18
19+
Masters

Ethnicity (In accordance
with US Census Bureau
guidelines, you may make
up to two choices, if
appropriate)

African-American
Asian or Pacific Islander
Caucasian
Hispanic
Native American
Other
Decline

In accordance with our privacy policy, certain contact information for non-athlete members is not shown on the MVS website unless specifically authorized by the member. Please chose an option below whether to have this information shown. Your USAS registration number will never be revealed even if you authorize the display of all other contact information.

By selecting the option "Authorized" below, I hereby consent to the publication on the MVS website of the following personal contact information I have provided to Missouri Valley Swimming, Inc. and/or United States Swimming, Inc. in connection with the administration of their activities and my involvement therewith:

Full Name	Street Address
City and State	Telephone Numbers
Email Address	Zip Code
Always shown regardless of authorization

To the greatest extent allowed by law, I agree to hold Missouri Valley Swimming, Inc. and USA Swimming, Inc. harmless from and against any and all claims arising from the publication of the information authorized above. This authorization shall remain in force until such time as I expressly withdraw it by notice to Missouri Valley Swimming, Inc.

Publish All Your
Contact Information?

Authorized

Not Authorized

If you are registering for a Family Membership, please complete the next section below for the SECOND non-athlete family member.

Second Member Registration

Last Name

Legal First Name

Middle Name

Preferred Name

Date of Birth

(mm-dd-yyyy)

Gender

Male Female

Club Name

Work Phone

A/C	Number	Ext

Fax Phone

A/C	Number

Cell Phone

A/C	Number

Email Address

Were they registered
with MVS last year?

Yes No

Have they ever been a
member of USA Swimming
under a different name?
If yes, under what name?

If registered in a different
LSC, which one?

Position

Full-Time Coach (primary income is from coaching)
Part-Time Coach (primary income NOT from coaching)
Official
Other

If registering as a coach,
their primary age group
(may be more than one)

10 & Under
11-12
13-14
15-16
17-18
19+
Masters

Ethnicity (In accordance
with US Census Bureau
guidelines, you may make
up to two choices, if
appropriate)

African-American
Asian or Pacific Islander
Caucasian
Hispanic
Native American
Other
Decline

Publish All Their
Contact Information?

Authorized

Not Authorized

Membership Type and Fees

Select the appropriate
membership type and fee

	USAS Fee	MVS Fee		Total Due
Individual	46.00	5.00	=	$51.00
Family	90.00	5.00	=	$95.00
Life	1000.00	5.00	=	$1005.00

MVS Non-Athlete Registration and Payment

Instructions

Your Registration

= Required Field

Last Name

Legal First Name

Middle Name

Preferred Name

Date of Birth

Gender

Club Name

Your Mailing Address

City

State

Zip Code

Home Phone

Work Phone

Fax Phone

Cell Phone

Email Address

Were you registered with MVS last year?

Have you ever been a member of USA Swimming under a different name? If yes, under what name?

If registered in a different LSC, which one?

Position

If registering as a coach, your primary age group (may be more than one)

Ethnicity (In accordance with US Census Bureau guidelines, you may make up to two choices, if appropriate)

Publish All Your Contact Information?

Second Member Registration

Last Name

Legal First Name

Middle Name

Preferred Name

Date of Birth

Gender

Club Name

Work Phone

Fax Phone

Cell Phone

Email Address

Were they registered with MVS last year?

Have they ever been a member of USA Swimming under a different name? If yes, under what name?

If registered in a different LSC, which one?

Position

If registering as a coach, their primary age group (may be more than one)

Ethnicity (In accordance with US Census Bureau guidelines, you may make up to two choices, if appropriate)

Publish All Their Contact Information?

Membership Type and Fees

Select the appropriate membership type and fee

Comments

Were you registered
with MVS last year?

Have you ever been a
member of USA Swimming
under a different name?
If yes, under what name?

If registered in a different
LSC, which one?

If registering as a coach,
your primary age group
(may be more than one)

Ethnicity (In accordance
with US Census Bureau
guidelines, you may make
up to two choices, if
appropriate)

Publish All Your
Contact Information?

Were they registered
with MVS last year?

Have they ever been a
member of USA Swimming
under a different name?
If yes, under what name?

If registered in a different
LSC, which one?

If registering as a coach,
their primary age group
(may be more than one)

Ethnicity (In accordance
with US Census Bureau
guidelines, you may make
up to two choices, if
appropriate)

Publish All Their
Contact Information?

Select the appropriate
membership type and fee