PPS: Pre-Pre-School Application

Child’s Information

First Name *

Last Name *

Child’s Date of Birth *

Age

Gender

Current Program

Primary Email *

Home Address *

City *

State *

Zip Code *

Parent/Guardian’s Information

Mother’s Name

Mother’s Email

Home Phone *

Work Phone

Cell Phone

Father’s Name

Father’s Email

Home Phone *

Work Phone

Cell Phone

Emergency Contact

Phone Number*

Physician’s Name

Physician’s Phone

What’s the best way for us to contact you?

Please list any physical conditions we should be aware of

The Epiphany Community Nursery School and MAGIC Activity Center do not discriminate on the basis of race, color, religion or national or ethnic origin in the administration of its admissions, educational or other school policies.