Level Up Interest Form

Level Up Interest Form

I want to earn more money! Please contact me about the Level Up program.*YesNo

---

You must be 18 years old or older to participate in this program.*I am 18 years old or older

I live in one of the following Indiana counties*: Jasper CountyLake CountyNewton CountyPorter CountyStarke County

Check all that apply*I'm currently employed, but I still struggle to make ends meet.I want to move up in a career, but I need to complete some education or training.I have reliable transportation.

Where do you currently work?*
I am interested in training in the following industry/field? (Select your primary choice.)*MedicalTrade union (carpentry, steelworkers, electrician, etc.)Trucking/CDLWeldingMachinery/CNCBeing an entrepreneurSomething elseI don't know
How did you learn about Level Up?*

Do you have a child registered at a local Boys & Girls Club? * YesNo

First Name*

Last Name*

Email*

Phone*

Address Line 1*

Address Line 2

Best time to call*