Registration Information - Adult Student
MoonSchool Student Name *
MoonSchool Student Name
For Which Class Are you Registering? *
Choose all the classes for which you've registered.
Primary Phone Number *
Primary Phone Number
Primary/Cell Number
Secondary Phone Number *
Secondary Phone Number
Secondary/Office/Home Number
Primary Address *
Primary Address
This is a required field. If your child has no allergies or medications, please write "none."
Emergency Contact #1 Name *
Emergency Contact #1 Name
"Emergency Contacts" should be a trusted person other than yourself.
Emergency Contact #1 Phone Number *
Emergency Contact #1 Phone Number
Emergency Contact #2 Name *
Emergency Contact #2 Name
"Emergency Contacts" should be a trusted person other than yourself.
Emergency Contact #2 Relationship to Student
Emergency Contact #2 Phone Number *
Emergency Contact #2 Phone Number
I allow to 42nd Street Moon to seek medical treatment for me in the event of a medical emergency.
Photo/Video Release *
If you were referred by someone, please write their full name.