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Name & Address

*STOP* If you already have an account, please call 309-732-7275 option 1 to get your information.

Please note that in order to create an account for a child you must create an account for an adult first. Additional family members can be added to your account during registration.

* Denotes a required field.

First Name

Middle Name

Last Name

Street Address

City, State, Zip Code

Add Mailing Address(if different from above)

Mailing Address

City, State, Zip Code

Contact Information

Please enter your contact information.

* Denotes a required field.

Primary Phone

Extension

Alternate Phone

Extension

Cell Phone

Cell Carrier

Yes, I agree to receive text messages

Email address

Yes! Please email me the latest news and information.

Yes! Please mail me the latest news and information.

Personal Information

Please enter your personal information.

* Denotes a required field.

Role in Family

Gender

Users must be 13 years of age or older.

Date of Birth

or Age Category

Main Contact

Customer Type

Subscription Lists

Medical Alert

Questions

Emergency Contact

Please enter your emergency contact(s).
* Denotes a required field.

First Name

Last Name

Relationship

Primary Phone

Extension

Other Phone

Extension

Add another Emergency Contact

First Name

Last Name

Relationship

Primary Phone

Extension

Other Phone

Extension

Account Information

Please enter your account information.

* Denotes a required field.

Email address

Add Alternate Login ID

Alternate Login ID

Password

Contain at least eight characters in length

Contain at least one letter and one number

Confirm Password

Security Question

Specify Your Question

Answer

Confirm Answer

By creating an account, you are agreeing to terms of use and privacy rights.

City of Rock Island:
Terms of Use | Your Privacy Rights

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Terms of Use | Copyright Policy | Your Privacy Rights

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