Socal Water Polo

Registration

Step 1 of 4

2017 All SOCAL Summer Picnic BBQ

Biographical Waiver Fees Payment Receipt
* Starred fields are required
First Name *
Preferred (Nickname)
Middle Name
Last Name *
Create Password
Sex *      Birth Date * (mm/dd/yyyy)
Phone
Home/Primary
Work/Secondary
Cell/Other *
Texting Cell number to receive texts Cell phone service provider
Email *
Street *
Street 2
City *
State*
ZIP *
USWP Number Exp. Date (12/31/yyyy)   USWP information/Sign-up
USWP Club Name
Left/Right-handed? Left   Right   Both
T-Shirt Size  (Adult)          
Parent/Guardian *   1)   2)
Emergency Contact (Parent, Spouse, etc)
Name *   Relation
Phone *
Name 2 *   Relation 2
Phone 2 *
Additional Information
(if no, leave blank)
(if no, leave blank)
(if no, leave blank)

Problem with this registration?

Powered by ClubAssistant.com   ©2003-2017   Page execution time: 48 ms