Nakayoshi Gakko Online Registration

Registration

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Please remember to include the name of your student(s) and if you are including a donation in the notes section of your Paypal transaction. All payments must be RECEIVED by February 28 to secure your spot.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name*

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

TB Data for adult working in classroom

Person auth. to pick up+phone*

Person auth. to pick up+phone

Interest in add'l volunteering*

Interest in board-Y/N*

Contact #1

Contact #1 (Person Will Be Primary and Billing Contact by Default) First Name*

Last Name *

Relationship*

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Who is your employer?

Employer

Employer Phone

Employer Notes

Contact #2

Contact #2 (optional - Might Not Receive All E-mail Communication) First Name

Last Name

Relationship

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Who is your employer?

Employer

Employer Phone

Employer Notes

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

Grade in Fall 2025*

Dentist and Phone #*

Special Needs - leave blank if none

Allergies (esp food) - leave blank if none*

Other pertinent medical information - leave blank if none

Primary Doctor and Phone #*

Fully Immunized against COVID-19-Y/N*

Date of most recent TB test/result*

Parent Board Mem-Curr/Past/Nev*

Child of NG Teacher-Y/N*

Ret stu/sib in 2024-Y/N*

Child of MVBT Member-Y/N*

MVBT Dharma School-Y/N*

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

Grade in Fall 2025*

Dentist and Phone #*

Special Needs - leave blank if none

Allergies (esp food) - leave blank if none*

Other pertinent medical information - leave blank if none

Primary Doctor and Phone #*

Fully Immunized against COVID-19-Y/N*

Date of most recent TB test/result*

Parent Board Mem-Curr/Past/Nev*

Child of NG Teacher-Y/N*

Ret stu/sib in 2024-Y/N*

Child of MVBT Member-Y/N*

MVBT Dharma School-Y/N*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

Grade in Fall 2025*

Dentist and Phone #*

Special Needs - leave blank if none

Allergies (esp food) - leave blank if none*

Other pertinent medical information - leave blank if none

Primary Doctor and Phone #*

Fully Immunized against COVID-19-Y/N*

Date of most recent TB test/result*

Parent Board Mem-Curr/Past/Nev*

Child of NG Teacher-Y/N*

Ret stu/sib in 2024-Y/N*

Child of MVBT Member-Y/N*

MVBT Dharma School-Y/N*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

Grade in Fall 2025*

Dentist and Phone #*

Special Needs - leave blank if none

Allergies (esp food) - leave blank if none*

Other pertinent medical information - leave blank if none

Primary Doctor and Phone #*

Fully Immunized against COVID-19-Y/N*

Date of most recent TB test/result*

Parent Board Mem-Curr/Past/Nev*

Child of NG Teacher-Y/N*

Ret stu/sib in 2024-Y/N*

Child of MVBT Member-Y/N*

MVBT Dharma School-Y/N*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size*

Grade in Fall 2025*

Dentist and Phone #*

Special Needs - leave blank if none

Allergies (esp food) - leave blank if none*

Other pertinent medical information - leave blank if none

Primary Doctor and Phone #*

Fully Immunized against COVID-19-Y/N*

Date of most recent TB test/result*

Parent Board Mem-Curr/Past/Nev*

Child of NG Teacher-Y/N*

Ret stu/sib in 2024-Y/N*

Child of MVBT Member-Y/N*

MVBT Dharma School-Y/N*

Enroll in Classes

Select Class

Add Another Student

Required Policies

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Questions or Concerns

Comments

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Who is your employer?

Contact #2

How can we contact you?

Who is your employer?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Required Policies

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