Socal Water Polo

Registration

2017 All SOCAL Summer Picnic BBQ

* Starred fields are required
First Name *
Preferred (Nickname)
Middle Name
Last Name *
Create Password
Sex *  
Birth Date * (mm/dd/yyyy)
Phone
Home
Work
Cell *
Texting Cell Mobile provider Same as Cell Number
Add Another Texting Cell Number
Email *
Add Another Email Address
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 *
(if no, leave blank)
(if no, leave blank)
(if no, leave blank)

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