SOUTHEASTERN LSC INFORMATION FORM FOR SWIMMERS WITH A DISABILITY 
This non mandatory form is for accommodation purposes. 
Name___________________________________________________________________ Address_________________________________________________________________ Team__________________ USA Registration # _______________________________ Age and Birth date: _________________________ Events to be swum: _______/_______/_______/_______/ 
________/________/_______/_______/_______/_______/_______/_______/ 
Type of Disability Blind___ Cognitive/Intellectual ___Deaf ___Physical___ Other___
Extent of Disability: Be specific e.g. totally or partially blind, totally or partially deaf, loss of one or more limbs, multiple disabilities, etc. 
_______________________________________________________________________________
The following person(s) will accompany the swimmer for any needed assistance: _______________________________________________________________________________
Accommodations requested, Examples: Lane #, inside lane, starter side preference, assistance to the blocks, water start, hand signals, etc.  _______________________________________________________________________________
Information gathered on this form will only be used for swimmers accommodation during Meet, and forwarded to the SE LSC Disability chair for purposes of evaluation and tracking Swimmers attendance and performance. The Disability Chair welcomes any feedback and or comments concerning your Meet experience. 

Meet Director Email 

Meet Referee Email 

Disability Chair Email - Robin Heller - robin@seastarsaquatic.org