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?
Your answer
Address (Street, City, State, Zip)
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Sex:
Mother's Name:
Your answer
Home Phone:
Your answer
Work Phone:
Your answer
Cell Phone:
Your answer
Father's Name:
Your answer
Home Phone:
Your answer
Work Phone:
Your answer
Cell Phone:
Your answer
Email:
Your answer
Siblings Names and Ages:
Your answer
Other Adults in home:
Your answer
Language other than English used in the home:
Your answer
Do you have a home church?
How did you hear about Miss Mollie's
Your answer
Other schools or groups attended:
Your answer
Please list any allergies or other medical concerns:
Your answer
Please list any specific fears or anxieties your child experiences:
Your answer
Which hand does your child prefer to use:
Your answer
Does your child have any problems with toilet habits?
Does your child have any speech problems?
Do you have any concerns about your child's behavior or emotional well-being?
What are your child's unique characteristics?
Your answer
What do you find most delightful about your child?
Your answer
Mother/Guardian Signature:
Your answer
Father/Guardian Signature:
Your answer
IN CASE OF EMERGENCY WHEN PARENTS CANNOT BE REACHED, PLEASE NOTIFY:
Name:
Your answer
Phone Number:
Your answer
Relationship:
Your answer
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