Household Information

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Member Information
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? *
Primary Member (First Name) *		Last *	Gender *	Male Female
Date of Birth (mm/dd/yyyy)	/ /	School Grade or highest grade completed highest grade completed
LEAVE BLANK: Secondary Member First Name and Last name		Last	Gender *	Male Female
Date of Birth (mm/dd/yyyy)		School Grade or highest grade completed highest grade completed
Primary Email (if U-M employee, use umich 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		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?
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

Please complete the following information about your household: