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Please complete the following information about your household:
Username
(for Web Login)
*
(up to 50 chars)
Password *
(up to 50 chars)
Re-Type to Confirm Password *
(up to 50 chars)
We will ask you these 2 Security/Challenge Questions if you forget your Password:
What is the name of your home town? *
What is the name of your favorite teacher? *
Member Information
Primary Member (First Name) *
Last *
Gender *
Male
Female
LEAVE BLANK: Secondary Member First Name and Last name
Last
Primary Email (if U-M employee, use umich address)* *
Re-Type to Confirm Email Address* *
Home Phone w/ area code *
(xxx)xxx-xxxx
Work Phone w/ area code
Extension
Address Information
Mailing Address *
Street Address
if different
City *
State *
Postal/Zip Code *
Country
Do you work for UofM *
No
Yes
Emergency Contact Information
1 - Name of Emergency Contact (First)
Last
Contact Phone w/ area code
Relationship
Other Information
How did you hear about this site?
Bulletin
Community Beat
E-mail
Employee
Flier
Friend
Household Mailing
Newspaper
Physician Referral
Record
Website
Would you care to be contacted via Email by us?
No
Yes
Would you like to receive information on future classes?
No
Yes
* REQUIRED DATA
