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CLUES Registration Request Form

  • Registration for the Polar Bear Protectors Workshop on March 15, 2014 is now CLOSED as the event is full.
  • Registration for the Frogs: Nature's Messenger Workshop on February 23, 2014 is no CLOSED as the event is full.

   

Fields in Bold are required      
Family Name:


This is a Required Field.
Example: Your Last Name followed by the word "Family" (Martin Family, Smith Family, Rodriguez Family, etc.)
Contact Information (For Head of Household):
  Title First Name M. I. Last Name  
Contact: This is a Required Field.> This is a Required Field.  
Your Birthdate:

Address This is a Required Field.
City A value is required. Please select a valid item.Please select an item. Zip A value is required.  
County A value is required.
Address Type:

 

   

Home Phone: A value is required.  
Work Phone:  
Cell Phone:
Preferred Phone Type: Please select an item.  

 
Personal Email: A value is required.Invalid format.  
Work Email: Invalid format.  
Email Type: Please select an item.< />  

 
Programs Desired:
Please select a valid item.
 

Registrations Desired:

Relative One Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:

Relative Two Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:
Relative Three Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:
Relative Four Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:
Relative Five Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:
Relative Six Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:
Relative Seven Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:
Relative Eight Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:
Relative Nine Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:
Relative Ten Information
First Name:
Last Name:
Birthdate:

 


It is easiest to select your birth year first, followed by the month and the day
Gender:
Relation to You:

Community Based Organization Please select a valid item.
 
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