Student Intake FormPlease take a moment to complete the following form for your child for the upcoming 2024-2025 Enrichment program. Student Intake Form Student Name * First Name Last Name Birthdate * MM DD YYYY Name of Home School or District * Please list any food allergies, or reply N/A if not any. * Any special accommodations or IEP? * How many days attending Level Up Academy 2 days/week 3 days/week 4 days/week 5 days/week Parent Info Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Emergency Contact Please include name and contact info different from above. Name First Name Last Name Emergency Contact Phone * (###) ### #### I understand that on July 15th I will be charged $200. This charge covers the 1st week of class, as well as student materials for the school year. This fee is non-refundable. * I Agree Thank you!
