CHICAGO MASTERS SWIM CLUB

____ Renewal ____New Membership ____New Address

Name________________________ Date of Birth_____________

Address__________________________ City_________________

USMS Reg. #_____________________ State_____ Zip________

Age____ Sex____ Phone (H)_____________(W)_____________

Email_________________________

Make check payable to Chicago Masters Swim Club

I, the undersigned 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 the risks inherent in Masters Swimming (training) and competition, including possible permanent disability or death and agree to assume all of these risks. I hereby waive any and all rights to claims for loss or damage arising out of the participation in the Chicago Masters Swim Club and any activities incident to membership thereto against U. S. Masters, Inc., Central Masters Swim Association, Chicago Masters Swim Club, the Chicago Park District, the Trustees of the University of Illinois, the University of Illinois at Chicago, their respective officers, agents and representatives, for any and all damages which may be suffered by me in connection with my association with or participation in any way with the Chicago Masters Swim Club and any of its sanctioned or approved activities.

Signature_________________________ Date_____________