Registration Information - Child/Teen Student
Primary Parent/Guardian's Name *
Primary Parent/Guardian's Name
Name of Registering Parent/Guardian
e.g. Parent, Guardian, Aunt, Uncle, Grandparent
Primary Parent/Guardian Phone *
Primary Parent/Guardian Phone
Primary/Cell Number
Primary Parent/Guardian Phone *
Primary Parent/Guardian Phone
Secondary/Office/Home Number
MoonSchool Student Name *
MoonSchool Student Name
Classes for Which You are Registering: *
Please choose only those for which you have already paid.
Student Birth Date *
Student Birth Date
Please enter Grade & School for the upcoming school year (starting Fall 2019)
Student Primary Address *
Student Primary Address
Additional Address
Additional Address
Please include additional address if student divides time between households. Leave blank if only one 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
Please list any persons authorized to pick up your child from MoonSchool.
Primary Doctor's Name
Primary Doctor's Name
Primary Doctor's Phone Number
Primary Doctor's Phone Number
I allow to 42nd Street Moon to seek medical treatment for my child in the event of a medical emergency.
Photo/Video Release *
If you were referred by someone, please write their full name.