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Learning Center

901 E. 2nd Street

Muncie, IN. 47302

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Application for Admission

First Name

Birthday

Middle Name

Gender

Last Name

Grade

Current school or child care center

Start Date

Parent/Guardian #1 Information

First Name

Middle Name

Last Name

Address

City

State

Zip

Cell

Employer name and phone number

Email

Birthday

Parent/Guardian #2 Information

First Name

Middle Name

Last Name

Address

City

State

Zip

Cell

Employeer name and phone number

Email

Birthday

Household Information

Number living in household

Primary lanuage

Do you have a CCDF Voucher

I attest that all of the above information is true and accurate as of the date below;

Your Signature

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