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Please complete the following. If you have any special instructions please note them in the Special Instructions box.
Please enter your login and password below.
Login
Password
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Student First Name
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Student Last Name
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Address
Address 2
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City
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State
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Zip Code
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Cell Phone
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Email
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Login
Login Rules
At least 4 characters, may include:
Letters
Numbers
Symbols: @ , _ , -
Period (.)
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Password
Strong Password Rules
The rules for strong passwords are:
At least 8 characters, but not longer than 20 characters
At least one upper case letter and lower case letter
At least one number
Cannot contain your name
Cannot be the same as your login or contain your login
Cannot be a reversal of the letters in your login
Must be a unique password each time you reset it
Password cannot be one you have already used
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Retype Password
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School Name
Waiting List Information
Appointment Type
Notes
Online scheduler session will expire in:
60
Seconds