Parents' Day Out Registration Form St. Mark's Episcopal Church in San Antonio, TX

Parents Day Out | Age-appropriate Groups | Professionally-trained Staff | Pricing Schedule |

Registration Form |

Welcome to our online registration form for St. Mark's Episcopal Church Parents' Day Out. Please complete the form below and click "Submit" to send your registration.

The form is intended to be very thorough so as to maximize your child's experience at Parents' Day Out. We keep all information STRICTLY CONFIDENTIAL. Please call Ruby Merrill if you have any questions at 210-226-2426 or you may email rmerrill@stmarks-sa.org.

ONE CHILD PER REGISTRATION FORM, PLEASE! If you are registering more than one child, please complete a separate registration form for each child.

IMPORTANT NOTE: A $100 NON-REFUNDABLE* REGISTRATION FEE IS DUE WITH THIS ENROLLMENT APPLICATION.

The application fee can be mailed to:
St. Mark's Episcopal Church
c/o Ruby Merrill - Parents' Day Out
315 E. Pecan St.
San Antonio, TX 78205

* A space for your child is not guaranteed without registration fee.
If we do not have space for your child, we will return your check.

<- If you prefer a printable PDF version of the registration form.

The PDF registration form in an interactive document. You will be able to complete
the entire form inside the document, print it and submit it.

You will need the most recent version of Adobe Acrobat. Click the link to download.

PERSON COMPLETING THIS APPLICATION

We will communicate with you confirming receipt of this application. Please provide your name, email address, telephone where you can be reached during the day and relationship to the child. THIS IS REQUIRED INFORMATION.

YOUR full name (required):

YOUR email (required):

YOUR phone # where we can reach you during the day (required):

YOUR relationship to the child (required):

PERSONAL INFORMATION

CHILD'S INFORMATION:

Child's LAST name:

Child's FIRST name:

Child's NICKNAME (if applicable):

CHILD'S GENDER:

Female

Male

Child's DATE OF BIRTH (mm/dd/yyyy):

CHILD'S HOME ADDRESS:

Child's home STREET:

Child's home CITY:

Child's home STATE:

Child's home ZIP:

CHILD RESIDES WITH:

Who does the child reside with?:

Both parents

Mother

Father

Other

If "Other", what is the relationship to the child?:

MOTHER'S INFORMATION:

Mother's LAST name:

Mother's FIRST name:

Mother's HOME TELEPHONE (555-555-5555):

Mother's BUSINESS TELEPHONE:

Mother's CELL TELEPHONE:

Mother's EMAIL:

(Please provide a good email address- we do lots of communication via email)

MOTHER'S ADDRESS:

Mother's address SAME as child (if checked, skip to next section):

Mother's home STREET:

Mother's home CITY:

Mother's home STATE:

Mother's home ZIP:

FATHER'S INFORMATION:

Father's LAST name:

Father's FIRST name:

Father's HOME TELEPHONE (555-555-5555):

Father's BUSINESS TELEPHONE:

Father's CELL TELEPHONE:

Father's EMAIL:

(Please provide a good email address- we do lots of communication via email)

FATHER'S ADDRESS:

Father's address SAME as child (if checked, skip to next section):

Father's home STREET:

Father's home CITY:

Father's home STATE:

Father's home ZIP:

PARENT'S MARITAL STATUS:

Marital Status:

Married (if checked skip next section)

Divorced/Separated (if checked complete next section)

Other (if checked skip next section)

If divorced, what are the custodial arrangements?:

Joint custody

Sole custody

Sole custody to

Other pertinent custody information:

FAMILY INFORMATION

Names, ages and school attending of child's siblings (one sibling/age/school per row):

CHURCH INFORMATION:

MOTHER attends St. Mark's::

Yes

If NO, name of church MOTHER attends:

FATHER attends St. Mark's::

Yes

If NO, name of church FATHER attends:

PARENTS' OCCUPATION-SKILLS-INTERESTS-HOBBIES:

MOTHER'S occupation, skills, interests, hobbies, etc.:

FATHER'S occupation, skills, interests, hobbies, etc.:

LANGUAGE SPOKEN AT HOME:

What is the PRIMARY language spoken at home?:

English

Spanish

Other

If OTHER, please specify primary language spoken at home:

FAMILY PETS

Does your family have any pets?:

Yes

If YES, what kind of pet[s] (i.e., dog, cat, bird, hamster, etc.):

What are your pet[s]' name[s]?:

TELL US ABOUT YOUR CHILD

How can we maximize your child's experience? What are your goals for this program?

What are your child's favorite toys or types of play activities?

How often does your child play with other children?

Does your child prefer to play alone?:

Yes

On occasion

Does your child seek a lot of adult attention while playing?:

Yes

Has your child previously had childcare or nursery school experience?:

Yes

If YES, where and at what age?

In general, would you characterize your child as more ACTIVE or RESERVED?::

Active

Reserved

What situations are upsetting or frightening to your child?

CHILD'S ALLERGIES/MEDICAL INFORMATION

Does your child have any food allergies?:

Yes

If YES, please specify food allergy:

Does your child have any other allergies?:

Yes

If YES, please specify other allergies:

Are there any particular eating issues (i.e., picky eater, etc.)?:

Yes

If YES, please describe eating issues:

Does your child have any medical conditions of which we should be made aware?:

Yes

If YES, please describe medical condition[s]:

CHILD'S DOCTOR'S INFORMATION (Please provide doctor's name and contact information including telephone number):

CHILD'S SLEEPING HABITS

What time does your child go to bed at night?:

What time does your child wake up in the morning?:

Does your child take a nap?:

Yes

If YES, how often and for how long?

Does your child take any special security item to bed?:

Yes

If YES, please describe:

Will they need this item to rest here?:

Yes

Please describe any sleeping problems/conditions (bed-wetting, nightmares, etc.):

CHILD'S BATHROOM HABITS

Is your child potty-trained?:

Yes

N/A (my child is an infant)

If NO, what are you currently doing to accomplish this (if applicable)?

Are there any specific bathroom habits that would be helpful for us to know?

CHILD'S BEHAVIOR

In what ways does your child deal with conflict, disappointment, or anxiety? (Please include behaviors such as withdrawal, anger, hitting, etc.)

How does he/she recover?::

Very slowly

Slowly

Quickly

Very quickly

In what ways have you discovered adults can help him/her recover?

What methods do you use to guide or discipline your child and what is his/her typical reaction?

Tell us what is wonderful about your child

What is wonderful about your child?

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