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 Sponsor (First)
Name of Primary Guardian (Last)
Gender
Date of Birth (mm/dd/yyyy)
School Grade
or highest grade
completed
Secondary Guardian Information
Name of Spouse (First)
Name of Secondary Guardian (Last)
Gender
Date of Birth (mm/dd/yyyy)
School Grade
or highest grade
completed
Email and Phone Information
Sponsor Email Address
Re-type to Confirm Email Address
Home Phone xxxxxxxxxxxxxxx
Cell Phone xxxxxxxxxxxxxxx
Work Phone xxxxxxxxxxxxxxx
Work Extension
Address Information
Mailing Address
Apt #
City
State
Postal/Zip Code
Country
Emergency Contact Information
Name of Emergency Contact (First) Name of Emergency Contact (Last) Contact Home Phone w/ area code Relationship

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