Non-Athlete Registration and Payment

Instructions

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.
Once you have completed this form, you will be sent automatically to the PayPal website to enter your payment information. No financial transactions are handled directly on this site.
PayPal accepts credit cards, debit cards and personal checks.
You will receive an email confirmation from PayPal once your payment has been approved.

PLEASE NOTE: USA Swimming now requires that ALL non-athlete members must satisfactorily pass a criminal background check as a condition of membership. This requirement went into effect on January 1, 2011. New registrations or re-registrations will be denied until the background check has been completed. You must initiate your background check prior to completing this form.

The cost of the background check for those registering as a "Coach" or "Official" is $39.00
The cost of the background check for those registering as "Other" is $19.00

To initiate the background check, proceed to http://www.usaswimming.org/backgroundcheck, click on "Initiate a Background Check" and follow the prompts.

WARNING! You do not have JavaScript enabled for your browser. This form uses JavaScript extensively to verify your data. You MUST enable JavaScript in your browser before proceeding further as this form WILL NOT work without it.

Your Registration

= Required Field

Last Name

Legal First Name

Middle Name

Preferred Name

(if different than first name)

Date of Birth

Month Day Year

Gender

Male Female

Club Affiliation

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

If formerly registered in a
different LSC, which one?

Registering as:

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 published on the MVS website unless specifically authorized by the member. Please chose from the options below to designate those items that are authorized for publishing. Your USAS registration number is never revealed even if you authorize the publishing of some or all of your contact information.

By selecting the "Authorized" options 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	Home Phone
Street Address	Work Phone
City, State & Zip	Fax Phone
Club Affiliation	Mobile Phone
Official's Certification	Email Address
Coach's Position	Registration Year
Always shown regardless of authorization status

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.

Contact
information
authorized
to be shown
on this website:

(check all that apply)

Address & City:

Authorized Not Authorized

Home Phone:

Authorized Not Authorized

Work Phone:

Authorized Not Authorized

Mobile Phone:

Authorized Not Authorized

Fax Phone:

Authorized Not Authorized

Email Address:

Authorized Not Authorized

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

Second Non-Athlete Registration

Last Name

Legal First Name

Middle Name

Preferred Name

Date of Birth

Month Day Year

Gender

Male Female

Club Affiliation

Work Phone

A/C	Number	Ext

Fax Phone

A/C	Number

Cell Phone

A/C	Number

Email Address

Was he/she registered
with MVS last year?

Yes No

Has he/she been a
member of USA Swimming
under a different name?
If yes, under what name?

If formerly registered in a
different LSC, which one?

Registering as:

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

If registering as a coach,
his/her 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

Contact
information
authorized
to be shown
on this website:

(check all that apply)

Address & City:

Authorized Not Authorized

Home Phone:

Authorized Not Authorized

Work Phone:

Authorized Not Authorized

Mobile Phone:

Authorized Not Authorized

Fax Phone:

Authorized Not Authorized

Email Address:

Authorized Not Authorized

Membership Type and Fees

Select the appropriate
membership type and fee

	USAS Fee	MVS Fee		Total Due
Individual	48.00	5.00	=	$53.00
Family	95.00	5.00	=	$100.00
Life	1000.00	5.00	=	$1005.00

Non-Athlete Registration and Payment

Instructions

Your Registration

= Required Field

Last Name

Legal First Name

Middle Name

Preferred Name

Date of Birth

Gender

Club Affiliation

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

If formerly registered in a different LSC, which one?

Registering as:

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)

Contact information authorized to be shown on this website:

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

Second Non-Athlete Registration

Last Name

Legal First Name

Middle Name

Preferred Name

Date of Birth

Gender

Club Affiliation

Work Phone

Fax Phone

Cell Phone

Email Address

Was he/she registered with MVS last year?

Has he/she been a member of USA Swimming under a different name? If yes, under what name?

If formerly registered in a different LSC, which one?

Registering as:

If registering as a coach, his/her 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)

Contact information authorized to be shown on this website:

Membership Type and Fees

Select the appropriate membership type and fee

Comments

Were you registered
with MVS last year?

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

If formerly 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)

Contact
information
authorized
to be shown
on this website:

Was he/she registered
with MVS last year?

Has he/she been a
member of USA Swimming
under a different name?
If yes, under what name?

If formerly registered in a
different LSC, which one?

If registering as a coach,
his/her 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)

Contact
information
authorized
to be shown
on this website:

Select the appropriate
membership type and fee