Southern California Aquatic Masters

Trial Workout

Step 1 of 3
Biographical Waiver Payment Receipt
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 *
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
Trial Workout Information
Date Attend (mm/dd/yyyy)
Facility attend Culver City Municipal Plunge, Culver City
Echo Park, Los Angeles
El Segundo, El Segundo
Hermosa Beach Ave 13
Loyola Marymount University, Los Angeles
Occidental College, Los Angeles
Redondo Union High School, Redondo Beach
Santa Monica - ONLY AVAILABLE TO SM RESIDENTS
Santa Monica Annenberg Beach House Tower 4
Santa Monica Beach Tower 26/end of Ocean Park Blvd
University of Southern California, Los Angeles
Van Nuys Sherman Oaks City Pool, Sherman Oaks
Westwood Recreation Center, Los Angeles
other

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