Level Up Junior Enrollment Form

WE ARE SUPER EXCITED FOR YOU TO JOIN US IN LEVEL UP JUNIOR! IF YOU HAVE DISCUSSED A SUITABLE CLASS TIME WITH Allie, PLEASE FILL OUT THE FORM BELOW TO SECURE YOUR SPOT AND COMPLETE YOUR REGISTRATION. 

Please note that this is a secure form that will be sent directly to Allie Friedman, the Level Up Junior Coordinator.

Student's Name *
Student's Name
Student's Date of Birth *
Student's Date of Birth
Parent or Contact Name *
Parent or Contact Name
If this enrollment is for an adult student, please just say "Adult Student".
If you are an adult student, please enter your email address here.
If you are an adult student, please enter your phone number here.
We accept Visa, Mastercard, and Discover credit cards. We also can process payment via ACH direct withdrawal from your checking account. Please note that there is a $4/month processing fee to use a credit card. There is no fee to use ACH. If you would like to switch to ACH after submitting this form to avoid the processing fee, please do so at any time during office hours.
MM/YY
This is the 3-digit code typically found on the back of your credit card.
Billing Address *
Billing Address
Location You Will Be Attending *