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Please complete the following information about your household:
Email Address
(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 your favorite sport? *
What's your favorite hobby? *
Head of Household Information
Name of Primary Guardian (First) *
(Last) *
Date of Birth (mm/dd/yyyy) *
/
/
Gender *
Male
Female
School Grade or highest grade completed highest grade completed *
Unspecified
Pre-K (0-3)
Pre-K (3-5)
Kinder
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Other
Name of Secondary Guardian (First) *
(Last) *
Date of Birth (mm/dd/yyyy) *
/
/
Gender *
Male
Female
School Grade or highest grade completed highest grade completed *
Unspecified
Pre-K (0-3)
Pre-K (3-5)
Kinder
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Other
Primary EMail 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/Province *
Postal/Zip Code *
Country
Do you live in South Burlington, VT? *
No
Yes
Emergency Contact Information
Name of Emergency Contact (First) *
(Last) *
Contact Phone w/ area code *
Relationship *
Other Information
How did you hear about this site?
Not Selected
Brochure
On-Line
Local Paper
Other
Would you care to be contacted via Email by us?
No
Yes
Would you care to participate in Promotions or Contests?
No
Yes
* REQUIRED DATA
