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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 ($195)

Address Information    
     
Local Address Apt#   
City State  
Zip  
Date of Birth Male Female
School

Additional Members (Partner)
 
Yes No
First Name Email
Last Name
  New ($235) Renewal ($195)

Number of New Members   x$235.00
Number of Renewing Members   x$195.00
  Total Charge: