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

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