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Parents' Day Out Online Registration

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 Heather Herschell if you have any questions at 210-226-2426 or you may email hherschell@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 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.
CLICK HERE for printable PDF form.   <- If you prefer a printable PDF version of the registration form.
CLICK HERE to download Acrobat Reader 8.0 (or later)  

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 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:

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:
Other pertinent custody information:

FAMILY INFORMATION

Names, ages and school attending of child's siblings (one sibling/age/school per row):
CHURCH INFORMATION:
If NO, name of church MOTHER attends:
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:
If OTHER, please specify primary language spoken at home:
FAMILY PETS
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?
If YES, where and at what age?
What situations are upsetting or frightening to your child?

CHILD'S ALLERGIES/MEDICAL INFORMATION

If YES, please specify food allergy:
If YES, please specify other allergies:
If YES, please describe eating issues:
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?:
If YES, how often and for how long?
If YES, please describe:
Please describe any sleeping problems/conditions (bed-wetting, nightmares, etc.):

CHILD'S BATHROOM HABITS

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.)
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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