2026 Level Up Skills Program Enrollment Forms

Typed signature acknowledgment Child name first and last Child date of birth Gender or pronouns Address City State ZIP Amanda Clearcreek Berne union Bloom Carroll Canal Winchester Other district Other district text Fairfield Union Lancaster Liberty Union Pickerington Walnut township 9th grade 10th grade Pickup person 1 name Pickup person 1 relation Pickup person 1 phone number Pickup person 2 name Pickup person 2 relation Pickup person 2 phone number Industrial Technology initials Drones initials

Known allergies or medical conditions Known dietary restrictions Parent or guardian name Parent or guardian telephone numbers Parent or guardian email Secondary emergency contact name Secondary emergency contact telephone numbers Secondary emergency contact email Primary care physician name Primary care physician contact number

In an emergency do staff have permission to transport the child

Yes No

Is there anything else we need to be aware of

Printed name for waiver Relationship to child Email address Telephone number Date Printed name for photo release Relationship to child for photo release Photo release date

Child name first and last Skills programs registered for Weeks attending Requested accommodations or modifications Additional information Date

Student name

NO YES If yes list name and relationship of individuals