21st Century Learning Center Application
Program Start: August 11th, 2025   Time: 3pm - 6pm
Program Location: Canaan Community Academy
Contact us: (812) 839-0003 or at jallard@canaanca.com
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How many students are you wanting to enroll? *
Name of Students *
What grade will your student(s) be in this year? *
Required
What days will your student likely come? *
Required
Name of Parent/Guardian  *
Parent/Guardian Email *
Parent/Guardian Phone Number *
Where would you like to pick you child up? *
Does your student attend Canaan Community Academy? *
Do we have permission to retrieve the medical and contact information through Canaan Community Academy for your student's(s') safety? *
Required
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