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2012-2013 STU-DENT REGISTRATION FORM

Please note: This form is for NON-NYU Students. Please do not use this form if you are currently an NYU Student.

Personal Information

First Name
Last Name
Phone Number Email
Primary Member   New ($235) Renewal ($193)
Address Information    
     
Local Address Apt#   
City State  
Zip  
Date of Birth Male Female
School
School Year Freshman Sophomore Junior Senior Grad Student
 
Additional Members (Partner)
 
Yes No
First Name Email
Last Name
Partner   New ($235) Renewal ($193)
Date of Birth Male Female
Local Address 
(if different than primary member's)		   Apt#   
City       State  
Zip    
Additional Members (Dependant)
Yes No
First Name
Last Name
Dependent   New ($83) Renewal ($83)
Date of Birth Male Female
Local Address
(if different than primary member's)		   Apt#   
City   State  
Zip
Number of New Members   x$235.00
Number of Renewing Members   x$193.00
Number of Dependents (Under 16)   x$83.00
  Total Charge:

  

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