Reimbursement Form

Swimmer wearing a white swim cap and black swimsuit on pool edge with hands on the ledge in a backstroke start position.

Swimmer underwater in a pool with blue water

Male swimmer performing butterfly stroke in indoor pool with his reflection on the water surface

Underwater view of a swimmer in a blue swimsuit and swim cap, swimming on their back in a pool.

Allegheny Mountain LMSC will reimburse up to five coaches and two officials per team for their USMS registration per year. This request must be submitted by the team’s head coach or designated delegate.

Please submit all other funding reimbursement requests here.

Important: If your club has already reimbursed you for registration, the LMSC will reimburse the club directly. Please do not submit duplicate requests.

Name of Submitter

First Name

Last Name

Email

Team Name

Coach 1

Address (Coach 1)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Coach 1)

(###)

###

####

Coach 2

Address (Coach 2)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Coach 2)

(###)

###

####

Coach 3

Address (Coach 3)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Coach 3)

(###)

###

####

Coach 4

Address (Coach 4)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Coach 4)

(###)

###

####

Coach 5

Address (Coach 5)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Coach 5)

(###)

###

####

Official 1

Address (Official 1)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Official 1)

(###)

###

####

Official 2

Address (Official 2)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Official 2)

(###)

###

####