PRESCHOOL APPLICATION
MISS MOLLIE'S SCHOOL OF GRACE
PRESCHOOL MORNING (9AM - 1PM)
A non-refundable fee of seventy-five dollars ($75.00) is due at time of application.
Choose Program:
PLEASE COMPLETE THE FOLLOWING INFORMATION:
Child's Name (Last, First) Nickname?
Address (Street, City, State, Zip)
Child's Date of Birth
MM
/
DD
/
YYYY
Sex:
Clear selection
Mother's Name:
Home Phone:
Work Phone:
Cell Phone:
Father's Name:
Home Phone:
Work Phone:
Cell Phone:
Email:
Siblings Names and Ages:
Other Adults in home:
Language other than English used in the home:
Do you have a home church?
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How did you hear about Miss Mollie's
Other schools or groups attended:
Please list any allergies or other medical concerns:
Please list any specific fears or anxieties your child experiences:
Which hand does your child prefer to use:
Does your child have any problems with toilet habits?
Clear selection
Does your child have any speech problems?
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Do you have any concerns about your child's behavior or emotional well-being?
Clear selection
What are your child's unique characteristics?
What do you find most delightful about your child?
Mother/Guardian Signature:
Father/Guardian Signature:
IN CASE OF EMERGENCY WHEN PARENTS CANNOT BE REACHED, PLEASE NOTIFY:
Name:
Phone Number:
Relationship:
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