MoonLight Jr. Registration | 42nd Street Moon

Submitted by ken on Mon, 01/31/2011 - 19:20

MasterCard, Visa, and American Express are welcome (5% order fee applies).
Please make checks payable to 42nd Street Moon.
Space is limited. Registration is on a first come, first served basis.
(Note, registration is only complete when tuition has been paid)*

Registration deadline: June 1, 2012

You can also download and print this form here: MoonLight Jr. Registration Form.

Please send completed forms and payment to:

42nd Street Moon, 601 Van Ness Avenue #E3-621, San Francisco, CA 94102

For questions please contact Dyan McBride, Education Director or call 415-255-8205 x 103.

*Until June 1, 2012 tuition includes a $100 non--refundable deposit. After June 15, 2012 all payments are final and are non--refundable.

Student Information

First Name: *

Last Name: *

Birthdate: *

Age: *

Address 1: *

Address 2:

City: *

State: *

Zip: *

Cell Phone: *

Home Phone: *

E-mail: *

Emergency Contract Name & Phone: *

Parent/Guardian 1

Name: *

Relation to student: *

Cell Phone: *

Home Phone:

Work Phone:

E-mail: *

Address (if different than above):

Parent/Guardian 2

Name:

Relation to student:

Cell Phone:

Home Phone:

Work Phone:

E-mail:

Address (if different than above):

Program: *

MoonLight Jr. only - 9am-12noon: $350 + order fee

MoonLight Jr. & Afternoon Arts - 9am-4pm: $700 + order fee

Payment Method: *

Check (please make check out to 42nd Street Moon)

Credit (click the link on the next page, after clicking register)

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