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:
(515) 282-6741
Mailing Address:
Active Interest Media, Creative Home Group
2200 Grand Avenue
Des Moines, IA, 50312
Account Information
Parent / Guardian Details
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.