Levy Learning Center Registration Please fill out the form below and press Submit: 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 Address City, State, ZIP Home Phone Cell Phone Work Phone Mother’s Email Address Father’s name Check if address is the same as student yes Address City, State, ZIP 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