UCLA Bruin Swim Club

Information Request

Step 1 of 3
Biographical Waiver Notes Confirmation
* Starred fields are required
Swimmer Information
First Name *
Preferred (Nickname)
Middle Name *
Last Name *
Birth Date * (mm/dd/yyyy)
School *  
Grade *
Phone
Home/Primary *
Secondary
Cell/Other
Email *
Street *
Street 2
City *
State *
ZIP *
Club/Team Affiliation
Club/Team (Maximum of 5 alphanumeric characters)
Club/Team Name
Member Number (14 characters formatted MMDDYYFFFMLLLL)
Parent/Guardian *   1)   2)
Emergency Contact (Parent, Spouse, etc)
Name *   Relation
Phone *
Name 2 *   Relation 2
Phone 2 *
(Parents must list themselves in addition to any other authorized individual.)
Enter a whole number.

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