Sports Medicine and Science Network Application

Submit one application only, please.

* 1. Last Name
* 2. First Name
3. Middle and/or Maiden Name
* 4. Business Name
* 5. Primary Business Address
* 6. City
* 7. State
* 8. Zip
* 9. Business Phone
10. Cell Phone
* 11. Email
* 12. Specialty (select all that apply):
















* 13. Credentials/Certifications (select all that apply)

































* 14. Education (institution, program, year, include internships and rotations)
* 15. Experience working with swimmers:
* 16. Experience with other athletes from other sports:
17. Experience participating in athletics:
* 18. Birth Date (for membership verfication purposes only)
* 19. I have read USA Swimming's Position on Dietary Supplements (posted at http://www.usaswimming.org/USASWeb/DesktopDefault.aspx?TabId=532&Alias=Rainbow&Lang=en). I understand that all dietary supplements are considered "Take at Your Own Risk." As a listed member of the Sports Medicine & Science Network, I agree to treat and educate all swimmers in accordance with this philosophy.
*Required