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Uplift Registration Page
UPLIFT Program Inquiry Form
First Name Parent or Caregiver
Last Name Parent or Caregiver
Email
Phone
Address
City
County
Postal/ Zip Code
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
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Austria
Azerbaijan
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Bahrain
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Belize
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Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
1st Child Information
First Name 1st Child
Last Name 1st Child
Child's Birth Date (Include Month, Day, Year)
Gender
Male
Female
Non-binary
Other
2nd Child Information
First Name 2nd Child
Last Name 2nd Child
Child's Birth Date (Include Month, Day, Year)
Gender
Male
Female
Non-binary
Other
3rd Child Information
First Name 3rd Child
Last Name 3rd Child
Child's Birth Date (Include Month, Day, Year)
Gender
Male
Female
Non-binary
Other
4th Child Information
First Name 4th Child
Last Name 4th Child
Child's Birth Date (Include Month, Day, Year)
Gender
Male
Female
Non-binary
Other
Note: Please complete a separate form if you have more than 4 children
Race
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Where did you hear about us?
A Friend or Colleauge
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Hospital / Medical Facility
Other
Disclaimer: Your confidential information is never shared. This information is for The Lonon Foundation and its programming only.
I have read, understood, and accepted the privacy policy for membership.
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