Please complete the following information about your household

* REQUIRED DATA
Username (up to 50 chars)
Password (up to 50 chars)
Re-Type to Confirm
Head of Household Information
Primary Member (First Name)
Name of Primary Guardian (Last)
Gender
Date of Birth (mm/dd/yyyy)
School Grade
or highest grade
completed highest grade completed
Secondary Guardian Information
LEAVE BLANK: Secondary Member First Name and Last name
Name of Primary Contact (Last)
Gender
Date of Birth (mm/dd/yyyy)
School Grade
or highest grade
completed highest grade completed
Email and Phone Information
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 (xxx)xxx-xxxx
Work Extension
Address Information
Mailing Address
Street Address if different
City
State
Postal/Zip Code
Country
Emergency Contact Information
Name of Emergency Contact (First) Name of Emergency Contact (Last) Contact Phone w/ area code Relationship

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