Student Registration Form
Fill out the form carefully for registration
Student Name
*
First Name
Middle Name
Last Name
Birthdate
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian’s Name
*
First Name
Last Name
Parent/Guardian's E-mail
*
example@example.com
Mobile Number
*
Format: (000) 000-0000.
Secondary Email
example@example.com
Emergency Contact
Name
*
First Name
Last Name
Emergency Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
*
Medical Concerns/Other information New Moon Art Studio should know about your child (* If none, indicate N/A)
*
Has your child participated in any previous New Moon Art Studio workshop/camp?
*
Yes
No
Anyone referred you?
Available Sessions (Please choose one)
*
Please Select
Thursday, 4:30pm - 6:00pm
Friday, 4:00pm - 5:30pm
Friday, 4:30pm - 6:00pm
Friday, 6:00pm - 7:30pm
Saturday, 9:00am - 10:00am
Saturday, 10:45am - 12:15pm
Saturday, 1:00pm - 2:00pm
My Subscriptions
*
prev
next
( X )
Beginner
$140.00
$
140.00
for each
month
Intermediate
$160.00
$
160.00
for each
month
Advance
$180.00
$
180.00
for each
month
Credit Card
Additional Note:
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: