Indiana High School Swimming Coaches Association
2004-2005 Membership Application and Fall Clinic Fee
-- PLEASE TYPE OR PRINT --
Coach Name:
 _________________________________
School:
 ______________________________________________
School Address:
 ______________________________________________
City, State Zip:
 _____________________________ ____ ___________
School Phone:
 (_____)_____-_________
School Fax:
 (_____)_____-_________
Email Address:
 _____________@___________________
Home Address:
 ______________________________________________
City, State Zip:
 _____________________________ ____ ___________
Home Phone:
 (_____)_____-_________
   
 
 Please Choose One of the Membership Plans
Indiana
 High School Swimming Coaches Association
National
 Interscholastic Swimming Coaches Association
American
 Swimming Coaches Association
________
  $20.00 IHSSCA Head Boys or Girls
________
  $25.00 IHSSCA Head for Both
________
  $15.00 IHSSCA Assistant or Diving Coach
________
  $55.00 IHSSCA & NISCA Boys or Girls
________
  $60.00 IHSSCA & NISCA for Both
________
 $110.00 IHSSCA, NISCA & ASCA Boys or Girls
________
 $115.00 IHSSCA, NISCA & ASCA for Both
Fall Clinic Registration Fee
  Clarion Hotel Waterfront Plaza Sept. 30 & Oct. 1, 2004
________
   $60.00 Fee (includes lunch on Thursday)
$________
 Total Fees Enclosed
2004-2005 will be my ____ year as a Head Swimming Coach
2004-2005 will be my ____ year as an Assistant or Diving Coach
Please mail check or money order made payable to the IHSSCA to:
Bart Braden
Franklin Central High School
6215 South Franklin Road
Indianapolis, IN.  46259
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