SwimRVA Rapids Water Polo Registration
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Athlete First Name *
Athlete Middle Initial *
Athlete Last Name *
Street Address *
City *
State *
Zip Code *
T-Shirt Size *
Swim Suit Size Male OR Female? *
Swim Suit Size *
Ethincity
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Sex *
Date of Birth *
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/
DD
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YYYY
Age *
Please give a brief description of your past Water Polo history: *
Please give a brief description of your past swimming history: *
Any medical conditions or allergies we should know about? *
Any disabilities you would like us to know about? *
Please explain from above...
Emergency Contact First and Last Name *
Emergency Contact Phone Number *
Insurance Carrier/Company Name *
Insurance Carrier Phone Number *
Primary Care Physician (PCP) Name *
PCP Phone Number *
Parent/Guardian #1 First Name *
Parent/Guardian #1 Last Name *
Mobile Phone Number *
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Mobile Carrier *
Work Phone Number
Home Phone Number
Email Address (Main Login) *
Parent/Guardian #2 First Name
Parent/Guardian #2 Last Name
Mobile Phone Number
Mobile Carrier
Email Address
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