MSJHS Grad Nite 2021 @ Great America

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Student's First Name *

Student's Last Name *

Student's School ID# *

Student's Cell Phone #: xxx-xxx-xxxx *

Student's Personal Email (Not FUSD account) *

Parent/Guardian's First Name *

Parent/Guardian's Last Name *

Parent/Guardian's Cell Phone #: xxx-xxx-xxxx *

Parent/Guardian's Email *

Street Address *

Emergency Contact Name (Different from Parent/Guardian above) *

Emergency Contact Phone #: xxx-xxx-xxxx *

List student's allergies to food or medicine. If none, type N/A *

Insurance Provider *

Insurance Group Number/Member ID *

Member Name for Insurance *

Payment Choice: Check or PayPal *

Check (Student's full name + parent phone # in memo line)

PayPal https://tinyurl.com/MSJHSgnonlinepay (Student's full name + parent email in memo)

Required

Completed Registration Forms emailed or dropped off? *

Dropped off at MSJHS Office

Required

Medications needed at event. If none, type None *

Student has special needs and will require accommodations (describe briefly). If none, type None *

Additional information for event organizers *

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