Please complete the following information about your household

* REQUIRED DATA
User Name (up to 50 chars, but no less than 6)
Password (up to 50 chars, but no less than 6)
Retype to Confirm
Head of Household Information
Name of Primary Guardian (First)
Name of Primary Guardian (Last)
Gender
Date of Birth (mm/dd/yyyy)
Secondary Guardian Information
Name of Secondary Guardian (First)
Name of Primary Guardian (Last)
Gender
Date of Birth (mm/dd/yyyy)
Email and Phone Information
Primary Email Address
Retype to Confirm Email Address
Alternate Email Address
Would you care to be contacted via Email by us?
Home Phone w/ area code (xxx)xxx-xxxx
Cell Phone w/ area code (xxx)xxx-xxxx
Work Phone w/ area code (xxx)xxx-xxxx
Work Extension
Address Information
Mailing Address
Street Address if different
City
State/Province
Postal/Zip Code
Country
Emergency Contact Information
Name of Emergency Contact (First) Name of Emergency Contact (Last) Contact Phone w/ area code Relationship

#1
#2
#3

Site best viewed with 1024 by 768 resolution. Recommended browsers are IE 8, FireFox 3, Safari 4, Google Chrome.

	Name of Emergency Contact (First)	Name of Emergency Contact (Last)	Contact Phone w/ area code	Relationship
#1
#2
#3