San Diego Shores Water Polo Club

Trial Workout

Step 1 of 3

Biographical
Waiver
Payment
Payment
Receipt

Instructions Fill in this form and submit it. After you submit it, you will be sent to a page that has all your information printed on a coupon. Print this coupon and bring it with you to a workout for your free trial.

* Starred fields are required

First Name *

Preferred (Nickname)

Middle Name

Last Name *

Birth Date *

School *

Graduation Month/Year *

Grade *

Phones

Home *

Work

Cell

Texting Cell

Mobile provider

Email *

Country *

Street *

Street 2

City *

State *

ZIP Code *

USWP Number *

Exp. Date

(12/31/yyyy) USA Water Polo information/Sign-up

Left/Right-handed?

Left Right Both

Height

In inches

Weight

pounds

T-Shirt Size *

[Adult]

XXL

Parent/Guardian *

Emergency Contact

Name *

Relation

Phone *

Name 2 *

Relation 2

Phone 2 *

Insurance Company Name / Phone:

Member/Group #:

Physician's Name / Phone:

Dentist Name / Phone:

Phones

Emergency Contact

Trial Workout Information