Royal Water Polo Academy - Online Registration

* Starred fields are required

First Name *

Preferred (Nickname)

Middle Name

Last Name *

Create Password

Sex *

Female Male

Birth Date *

School *

Graduation Month/Year *

Grade *

Home

Work

Cell *

Texting Cell

Mobile provider

Email *

Country *

Street *

Street 2

City *

State *

ZIP Code *

Name *

Relation

Phone *

Name 2 *

Relation 2

Phone 2 *

Family Health Insurance Company:

Policy Number:

Primary Physician & Phone #:

Emergency Information: Please list ALL Allergies, Current medical conditions and medications

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SAT

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Non-Weighted GPA