Southern California Aquatic Masters

Online Registration

Step 1 of 3
Biographical Waiver Payment Receipt
Please make sure to read "Membership Obligations" and "Release of Liability" thoroughly on page two.
Instructions  To become a SCAQ member, please complete this 2-step registration form.  On step 2 you will be asked for your credit card (Visa, MasterCard) information.  Once you complete step 2 and submit the form, you are immediately eligible to participate.
* 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 *
Email *
Street *
Street 2
City *
State*
ZIP *
Employer * (Name of the company)
Profession
Street   Street 2
City   State   ZIP
Emergency Contact (Parent, Spouse, etc)
Name *   Relation
Phone *
Name 2 *   Relation 2
Phone 2 *
Interested in joining the Member Network?   Yes   Please send info
Additional Information
Club Name
Club Name

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