Levy Learning Center Registration

Student’s Name (required)

School Attended

Primary Email Address (required)

Teacher

Teacher’s email address

School Counselor
Counselor’s email address

Grade
—Please choose an option—Pre-KK1st grade2nd grade3rd grade4th grade5th grade6th grade7th grade8th grade9th grade10th grade11th grade12th grade Student’s Date of Birth

Referred by

Student’s Address
City, State, ZIP

Student’s Home Phone (required)
Student’s Cell Phone (if applicable)

Parents are (check one)

MarriedDivorcedSeparatedPartners

Mother’s name

Check if address is the same as student yes

Home Phone
Cell Phone

Work Phone
Mother’s Email Address

Father’s name

Check if address is the same as student yes

Home Phone
Cell Phone

Work Phone
Father’s Email Address

Guardian’s name (if applicable)

Address (if different)
City, State, ZIP

Cell Phone
Work Phone

Guardian’s Email Address

Δ