Moondance

Moondance Minor Child Registration Form

* = Required Fields

IF YOUR CHILD UNDER THE AGE OF 19 IS ATTENDING MOONDANCE WITH SOMEONE OTHER THAN THE PARENT OR LEGAL GUARDIAN, PLEASE FILL OUT THE FOLLOWING INFORMATION.

PLEASE NOTE! The information below is required for my records, so you may submit it on-line for convenience and time, but an original signature from a parent or legal guardian is required for permission for a minor to attend, so please print out this form, and mail it in and/or send it with the child to Moondance.

CHILD'S INFO:

*Legal Name (1):
*Child's or Parent's E-Mail Address (1): (so I can email the child or parent the confirmation flyer)
*Age (1):
*Date of Birth (1):

Legal Name (2):
E-Mail Address (2):
Age (2):
Date of Birth (2):

*Address:
*City: *State: *Zip:

Home Phone:

Any allergies or medical problems we should know about?

PARENT OR LEGAL GUARDIAN'S INFO:

*Mother's Name:
*E-Mail Address (1):

*Father's Name:
E-Mail Address (2):

*Address:
*City: *State: *Zip:

Home Phone:
Cell Phone:
Work Phone:

ACCOMPANYING PERSON'S INFO (Person(s) authorized to take your child(ren) to Moondance):

*Accompanying Person's Name:
*E-Mail Address:
*Address:
*City: *State: *Zip:

Home Phone:
Cell Phone:
Work Phone:

GENERAL WAIVER AND INFORMED CONSENT TO PARTICIPATE

*I, (legal name), parent or legal guardian of * (child's legal name), do give permission for my child to attend Moondance in the company of * (legal name of person accompanying child). I have read and understood the rules and standards of conduct expected while at Moondance, held Memorial Day weekend in May, at Roxanna, and agree that my child will act within these rules. I also understand that if my child does not abide by these, he/she may be escorted from the site without refund. I also agree to hold harmless the owners of the site of Roxanna, the organizers and staff of Moondance, and all its representatives, from all claims, actions, expenses and demands in respect to injury, loss or damage to my person or property, however caused, arising in connection with my participation even if the same may have been contributed to or occasioned by the negligence of the owners, the said body, or of any of its representatives.




Please type your full legal name below; this will be your electronic signature)

*Signature of parent or legal guardian
*Date signed:

Method of Payment for Child:
I will be paying via PayPal momentarily
I will be mailing a check or money order (paying whatever the current price is when I mail my check)
I will be paying at the gate ($25.00 weekend, $10 daytrip/day, cash, ages 11-17 and up)

PLEASE PRINT A COPY OF THIS PAGE FOR YOUR RECORDS, *BEFORE* CLICKING THE SUBMIT BUTTON BELOW!!

When you click the button below, you will automatically be directed to the PayPal Payment Page. NOTE: If you just want to mail a check or money order, or pay at the gate, go ahead and click the button, but then simply ignore the PayPal page, and hit your Back button to come back to this page; if you want, you can print this page and mail with your payment to the address below (a good idea if you're paying for multiple things). Your registration information that you filled in above will be sent to me automatically.