EmailMe Form - Registration: Spring/Summer 2016

SURREY ORCA'S WATER POLO CLUB

ATHLETE INFORMATION:
Athlete's Name: *
First Last
Athlete's Email Address:
Enter an email address ONLY IF DIFFERENT than primary or secondary parent address – this email address belongs to the athlete.
Athlete's Address: *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Athlete's Date of Birth: *
MM / DD / YYYY
Gender: *
Male
Female
Athlete's Medical Card Number: *
No spaces between the numbers please!
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Surrey Orca's Water Polo Club | Located in the Guildford Aquatics Centre, Surrey, B.C.