Please print this form, fill it in and either fax it to the number below or mail it to the provided mailing address.

Fax Number:

 

Mailing Address:

Account Information

Username:

Email:

Parent / Guardian Details

Full Name:

Relation:

Phone #:

Email:

I understand that the information I have provided is truthful, that any information may be changed in the future by entering the supplied password and this user account can be removed by request.

Signature:

Date: