Level Up Literacy Program

Student's Full Name

Student's Primary Address

Allergies and Care Plan/Emergency Medications

Student's school in fall

Student's grade in fall

Age & Date of Birth

Gender

Parent/Guardian Name

First Name

Last Name

Parent/Guardian's Phone

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Parent/Guardian Name

First Name

Last Name

Parent/Guardian's Phone

(###)

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Contact #3 Name

First Name

Last Name

Contact #3 Phone

(###)

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Student's Learning/Academic Strengths

List other student strengths and/or interests

List or describe the student’s learning weaknesses

Write any other comments you feel would be helpful for our teachers to know or understand about your student

Dates my child will attend:

Must total 40 hours

Dates my child will NOT attend:

Preferred Session Choice Selection

The 10:30-12:30 session is full. Every effort will be made to accommodate your choice. If your choice cannot be fulfilled, you will be contacted to make an alternate plan.

How did you hear about Level Up Literacy Program?

Thank you! Your registration form has been submitted. To complete your registration, submit $100 registration fee to Level Up Literacy. Email levelupliteracyprogram@gmail.com for contact information.

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