CUSTOMER REGISTRATION
CUSTOMER INFORMATION
First Name
*
Last Name
*
Date of Birth
*
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Year
Gender
*
Male
Female
Other
Person Type
Individual
Family
Family Role
Not Applicable
Student
Yes
No
School Name
Grade
Address Details
Line 1
Line 2
( Optional )
Country
State
City
Postal Code
*
Phone Number & Email
( Optional )
Email address
*
Contact Preference
*
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Email
Phone
Text
Email
Phone
Password
*
Confirm Password
*
password doesn't match.
FAMILY MEMBERS
Member 2
First Name
Last Name
Family Role
Gender
Male
Female
Other
Phone
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Year
Email address
Member 3
First Name
Last Name
Family Role
Gender
Male
Female
Other
Phone
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Year
Email address
Member 4
First Name
Last Name
Family Role
Gender
Male
Female
Other
Phone
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Year
Email address
Member 5
First Name
Last Name
Family Role
Gender
Male
Female
Other
Phone
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Year
Email address
Member 6
First Name
Last Name
Family Role
Gender
Male
Female
Other
Phone
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Year
Email address
TERMS AND CONDITIONS
Check here to indicate that you have read and agree to the
Terms of Service
and
Covid-19waiver.
Check here to indicate that you have read and agree to the
Terms of Service
and
Covid-19waiver.
Check here to indicate that you have read and agree to the
Participation Agreement
and
Policies and Procedures.
Check here to indicate that you have read and agree to the
Policies and Terms and Conditions
and
Waiver.
Check here to indicate that you have read and agree to the
Terms and Conditions.
Signature
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