Contact/Billing Information 

Name:

Club:

Address:

Phone: Fax:

Email:

CC# Exp.

      VISA         Master Card         American Express

Cost is $1000 US dollars per application.

Coaching History

Professional Qualifications/Certification Level

ASCA Level 1 2 3 4 5

     Other:

Education BA Masters PhD Associates (To select multiple degrees hold cltr key)

     Other:

Years in Coaching

Have you ever been involved in any coaching mentoring program? Yes No

Level of swimmers you have directly coached and the # of years you have coached them.

             World Record Holder - Number of swimmers 0 1 2 3 4 5 6 7 8 9 10   Years:

             American Record Holder - Number of swimmers 0 1 2 3 4 5 6 7 8 9 10   Years:

             Olympic Medalist - Number of swimmers 0 1 2 3 4 5 6 7 8 9 10   Years:

             World Championship Medalist - Number of swimmers 0 1 2 3 4 5 6 7 8 9 10   Years:

             Pan Pac/Pan Pam Medalist - Number of swimmers 0 1 2 3 4 5 6 7 8 9 10   Years:

             National Winner - Number of swimmers 0 1 2 3 4 5 6 7 8 9 10   Years:

Present Club Profile

Are you the  Owner

                     CEO

                     Partner

                     Other

How many years has the club existed?

Include Mission and Vision statement.

Number of swimmers with Olympic Trials cuts

Number of swimmers at US Open/Nationals

Number of swimmers with Sectional cuts

Number of swimmers with Top 16 Age Group Times

Total number of USA Swimming registered swimmers.

Do you run a SwimAmerica or other similar program? No Yes

                    If yes, what is the total number of users monthly

                    And... what is the total number of users annually

Other forms of income that is generated by your team.

Swim Shop Seasonal Swimmers Competitions/Meets (To select multiple degrees hold cltr key)

Other:

Facility

25y 8 lane pool Rented Owned Public Private

25y 10 lane pool Rented Owned Public Private

25m 8 lane pool Rented Owned Public Private

25m 10 lane pool Rented Owned Public Private

50m 8 lane pool Rented Owned Public Private

50m 10 lane pool Rented Owned Public Private

Other Rented Owned Public Private

Previous Club you were Attached to

Total 1 2 3 4 5 6 7           Team           Team

                               Position            Position

                               Years                                      Years

                               Team           Team

                               Position            Position

                               Years                                      Years

Previous swimmers you coached to...

                Olympic Team

                National Team

                National Titles

                National Qualifiers

                Number of Swimmers earned college scholarships 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100 100 +

Years involved in LSC or USA Swimming.