Application for Admissionto Level Up Academy Enrichment Program Child's Information Full Name * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Please note: Upon enrollment in our program, we will need a copy of your child's birth certificate. Parent/Guardian Information Parent/Guardian 1: * First Name Last Name Relationship to Child * Email * Phone * (###) ### #### Parent/Guardian 2: First Name Last Name Relationship to Child Email Phone (###) ### #### Enrollment Information Desired Program: * Half-Day Time: 12:15-2:45pm Half-Day 3 days/week Select if interested in 4-5 days Does your child have any previous school or childcare experience? * If yes, please provide details. Health and Development Does your child have any allergies or medical conditions we should be aware of? * If yes, please specify. Is there anything else you would like us to know about your child? (Speech, OT, PT, etc.) * Emergency Contact Information Name * First Name Last Name Relationship * Phone * (###) ### #### Agreement and Signature By signing below, I acknowledge that the information provided is accurate to the best of my knowledge and understand that this application does not guarantee enrollment. * Today's Date * MM DD YYYY Thank you!
