Long Beach State University Masters

Trial Workout

Step 1 of 3
Biographical Waiver Payment Confirmation
Instructions  Please fill out this form and submit it.  After you submit it, you will be sent to a page that has all your information printed on a coupon.  Please print this coupon and bring it with you to a workout for your free trial.
* Starred fields are required
First Name *
Preferred (Nickname)
Middle Name
Last Name *
Birth Date * (mm/dd/yyyy)
Phone
Home/Primary
Work/Secondary
Cell/Other *
Email *
Street *
Street 2
City *
State *
ZIP *
2017 U.S. Masters Swimming (USMS) Club/Team Affiliation
Club/Team (Maximum of 5 alphanumeric characters)
Club/Team Name
Member Number use all 10 digits, i.e. 3348-0000A
Register for USMS | Retrieve USMS Number
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 *
Trial Workout Information
Date Attend (mm/dd/yyyy)
Facility attend Long Beach Campus Pool, Long Beach
other

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