Please complete the following information about your household

* REQUIRED DATA
User Name (up to 50 chars)
Password (up to 50 chars)
Re-Type to Confirm
Head of Household Information
Name of Primary Guardian (First)
Name of Primary Guardian (Last)
Gender
Secondary Guardian Information
Name of Secondary Guardian (First)
Name of Primary Guardian (Last)
Gender
Email and Phone Information
Primary EMail Address
Re-Type to Confirm EMail Address
Home Phone w/ area code (xxx)xxx-xxxx
Cell Phone w/ area code (xxx)xxx-xxxx
Work Phone w/ area code (xxx)xxx-xxxx
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Address Information
Mailing Address
Street Address if different
City
State/Province
Postal/Zip Code
Emergency Contact Information
Name of Emergency Contact (First) Name of Emergency Contact (Last) Contact Phone w/ area code Relationship

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	Name of Emergency Contact (First)	Name of Emergency Contact (Last)	Contact Phone w/ area code	Relationship
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