The Daddy Lacy Project 
The Algebra Academy Application 
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Name (Student) *
Birthdate (Student) *
MM
/
DD
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YYYY
Email Address (Student School Email) *
Name of Parent(s) *
Home Address *
Phone Number (Best Contact Number) *
Email Address (Parent) *
Is there any information you would like to share with us concerning your child? Health conditions, learning disabilities, food allergies, etc... If there is no further information, please type "none" in the response box.
*
Would you like to participate in the parent program offered by Mississippi County Literacy Council (MCLC) while your child is receiving math instruction?  *
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