Name *

First Name

Last Name

Phone *

(###)

###

####

Birth Date *

MM

DD

YYYY

Citizenship *

U.S. Citizen

Not a U.S. Citizen

Are you a Michigan Resident? *

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian's Phone Number *

(###)

###

####

Parent/Guardian's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country