Simon Says

ADMISSION DATE Please enter valid data.

CHILD'S NAME (LAST, FIRST, MI) REQUIRED Please fill out this field. Please enter valid data.

Last 4 digits of child's SS# REQUIRED Please fill out this field. Please enter valid data.

GENDER FEMALE MALE

DATE OF BIRTH REQUIRED Please fill out this field. Please enter valid data.

ADDRESS (STREET, CITY, STATE, ZIP) REQUIRED Please fill out this field. Please enter valid data.

IDENTIFYING INFORMATION

WHO IS PRIMARY PERSON RESPONSIBLE FOR PAYMENT REQUIRED Please fill out this field. Please enter valid data.

SECONDARY RESPONSIBILITY? REQUIRED Please fill out this field. Please enter valid data.

RELIGION REQUIRED Please fill out this field. Please enter valid data.

ARE YOU A REGISTERED PARISHIONER AT ST. SIMON THE APOSTLE CHURCH YES NO

PARENTS MARITAL STATUS SINGLE MARRIED DIVORCED SEPARATED WIDOWED

MOTHER'S/GUARDIAN'S NAME (LAST, FIRST, MI) REQUIRED Please fill out this field. Please enter valid data.

DATE OF BIRTH REQUIRED Please fill out this field. Please enter valid data.

HOME PHONE WITH AREA CODE REQUIRED Please fill out this field. Please enter valid data.

ADDRESS (STREE, CITY, STATE, ZIP) REQUIRED Please fill out this field. Please enter valid data.

CELL PHONE WITH AREA CODE REQUIRED Please fill out this field. Please enter valid data.

CELL PHONE PROVIDER REQUIRED Please fill out this field. Please enter valid data.

EMAIL REQUIRED Please fill out this field. Please enter valid data.

EMPLOYER OR SCHOOL ATTENDING REQUIRED Please fill out this field. Please enter valid data.

EMPLOYER/SCHOOL ADDRESS REQUIRED Please fill out this field. Please enter valid data.

WORK/SCHOOL SCHEDULE REQUIRED Please fill out this field. Please enter valid data.

WORK PHONE REQUIRED Please fill out this field. Please enter valid data.

FATHER'S/GUARDIAN'S NAME (LAST, FIRST, MI) REQUIRED Please fill out this field. Please enter valid data.

DATE OF BIRTH REQUIRED Please fill out this field. Please enter valid data.

HOME PHONE WITH AREA CODE REQUIRED Please fill out this field. Please enter valid data.

ADDRESS (STREET, CITY, STATE, ZIP) REQUIRED Please fill out this field. Please enter valid data.

CELL PHONE WITH AREA CODE REQUIRED Please fill out this field. Please enter valid data.

CELL PHONE PROVIDER REQUIRED Please fill out this field. Please enter valid data.

EMAIL REQUIRED Please fill out this field. Please enter valid data.

EMPLOYER/SCHOOL ATTENDING REQUIRED Please fill out this field. Please enter valid data.

EMPLOYER/SCHOOL ADDRESS (STREE, CITY, STATE, ZIP) REQUIRED Please fill out this field. Please enter valid data.

WORK/SCHOOL SCHEDULE REQUIRED Please fill out this field. Please enter valid data.

WORK PHONE REQUIRED Please fill out this field. Please enter valid data.

EMERGENCY CONTACT AND PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY (OTHER THAN PARENT) AT LEAST ONE ADDITIONAL EMERG CONTACT IS REQUIRED

1. NAME REQUIRED Please fill out this field. Please enter valid data.

REALTIONSHIP TO CHILD REQUIRED Please fill out this field. Please enter valid data.

ADDRESS (STREET, CITY, STATE, ZIP) REQUIRED Please fill out this field. Please enter valid data.

PHONE NUMBERS (CELL, WORK, HOME) REQUIRED Please fill out this field. Please enter valid data.

2. NAME (2ND CONTACT OPTIONAL) Please enter valid data.

RELATIONSHIP TO CHILD Please enter valid data.

ADDRESS (STREET, CITY, STATE, ZIP) Please enter valid data.

PHONE NUMBERS (CELL, WORK, HOME) Please enter valid data.

3. NAME (3RD CONTACT OPTIONAL) Please enter valid data.

REALTIONSHIP TO CHILD Please enter valid data.

ADDRESS (STREET, CITY, STATE, ZIP) Please enter valid data.

PHONE NUMBERS (CELL, WORK, HOME) Please enter valid data.

CHILD'S PROJECTED ATTENDANCE SCHEDULE AND ANY VARIATION EXPECTED

CHECK HERE WHAT DAYS CHILD WILL ATTEND PRESCHOOL MON TUES WED THURS FRI

TYPE ANY COMMENTS, CHANGES OR VARIATIONS IN USUAL ATTENDANCE IN THIS SECTION INCL. SHIFT CHANGES.

PHYSICIAN OR CLINIC NAME REQUIRED Please fill out this field. Please enter valid data.

PHONE REQUIRED Please fill out this field. Please enter valid data.

PREFERRED HOSPITAL REQUIRED Please fill out this field. Please enter valid data.

HOSPITAL PHONE REQUIRED Please fill out this field. Please enter valid data.

OTHER ALLERGIES (PLEASE SPECIFY)

ANY KNOWN MEDICAL CONDITIONS

POTTY TRAINING STATUS REQUIRED IN DIAPERS IN TRAINING FULLY POTTY TRAINED Please fill out this field.

COMMENT ON CHILD'S DEVELOPMENT (NOTE CHILD'S PERSONAL DEVELOPMENT, BEHAVIOR, PATTERNS HABITS, AND INDIVIDUAL NEEDS)

I HAVE BEEN NOTITFIED THAT A COPY OF THIS FACILITY'S POLICIES PERTAINING TO THE ADMISSION, CARE AND DISCHARGE OF CHILDREN IS MAINTAINED ON THEIR WEBSITE (www.simonsaysecc.com). REQUIRED Yes Please fill out this field.

THE PROVIDER AND I HAVE AGREED ON A PLAN FOR CONTINUING COMMUNICATION REGARDING MY CHILD'S DEVELOPMENT, BEHAVIOR AND INDIVIDUAL NEEDS. REQUIRED Yes Please fill out this field.

WHEN MY CHILD IS ILL, I UNDERSTAND AND AGREE THAT S/HE MAY NOT BE ACCEPTED FOR CARE OR REMAIN IN CARE. REQUIRED Yes Please fill out this field.

I UNDERSTAND THAT, BEFORE THE FIRST DAY OF ATTENDANCE BY MY CHILD, I WILL PROVIDE PROOF OF COMPLETED AGE-APPROPRIATE IMMUNIZATIONS OR EXEMPTION FROM IMMUNIZATIONS. REQUIRED Yes Please fill out this field.

I GIVE PERMISSION FOR THE FACILITY TO TRANSPORT MY CHILD ON FIELD TRIPS (AGES 2.5 YEARS AND OLDER). REQUIRED Yes No Please fill out this field.

I GIVE PERMISSION FOR MY CHILD TO BE PHOTOGRAPHED. REQUIRED Yes No Please fill out this field.

I GIVE MY CONSENT TO INCLUDE PHOTOGRAPHS OF MY CHILD ON THE SIMON SAYS EARLY CHILDHOOD CENTER OR ST. SIMON THE APOSTLE CATHOLIC CHURCH WEBSITES. REQUIRED Yes No Please fill out this field.

I give permission for my child's photo to be used on social media. REQUIRED yes No Please fill out this field.

MY INFORMATION CAN BE INCLUDED IN THE SIMON SAYS BUZZBOOK. REQUIRED Yes No Please fill out this field.

This form was acknowledged and signed by (insert name): REQUIRED Please fill out this field. Please enter valid data.