MoonSchool Student Registration Student Information Form Each student (adult or child) must fill out the following form prior to enrolling in a MoonSchool class. If you have any questions regarding this form, please call 415-255-8205 or e-mail dyan@42ndstmoon.org. If the student is over 18, enter n/a for Parent/Guardian information. If you have filled out a form for your student in the last six months and no information has changed, please click here to go directly to the class registration page. Contact InformationStudent Full/Legal Name*Nickname/Likes to be CalledBirth date*Enter as mm/dd/yyyyStreet Address*City/State/Zip Code*Student E-mail (if applicable)Student Phone (if applicable)Enter as xxx-xxx-xxxxAs of September 2017, student will be in grade:At which school?Parent/Guardian/Emergency ContactAll students (regardless of age) must enter at least one emergency contact.Name*Relationship to Student*Address (if different from Student)Phone 1*Enter as xxx-xxx-xxxxPhone 2Enter as xxx-xxx-xxxxE-mail*Check all that apply: Authorized to pick-up/drop-off Can authorize medical treatment Parent/Guardian 2/Back-up Emergency ContactStudents over 18 may enter n/a in this section.Name*Relationship to Student*Address (if different from Student)Phone 1*Enter as xxx-xxx-xxxxPhone 2Enter as xxx-xxx-xxxxE-mail*Check all that apply: Authorized to pick-up/drop-off Can authorize medical treatment Health/Medical InformationAll students must fill out regardless of age.Allergies/Medical Conditions*Enter "none" if applicablePrimary Care PhysicianPhysician Phone NumberStudent Health Insurance Provider*Policy Number*Consent WaiverPhoto Release Consent By checking here, I hereby grant permission for the student named above to appear in photographs that may be published in hard copy publications (e.g., newsletters, brochures, newspapers), and/or on our web site or e-blasts. The copyright for all photographs will be held by 42nd Street Moon. This copyright includes any and all rights to include the picture in present and future publications of the company, in any format or media. Names are not used with photos.
