ABOUT US
About SSJ & Mission
Annual Report
Faculty and Staff
Little Explorers Preschool
School Board
School Security
History
Archdiocese of Philadelphia
ADMISSIONS
Request Information or Tour
Apply Now
Registration Application
Continuous Enrollment
Continuous Enrollment Agreement
Opt-Out Form
Financial Aid
Tuition Payments and Scrip
CARES (Before & After School Care)
CARES ON LINE REGISTRATION FORM
Health Emergency Information Form
Testimonials
FAQs
ACADEMICS
Academic Overview
Teachers & Classrooms
Academic Support
Academic Enrichment
Specials
ACTIVITIES
Explorers Summer Camps
SSJ Theatre Jr. Fall Musical
Cast Parents
CALENDAR
TICKETS
Spring Musical
Student Activities & Clubs
Service Opportunities
CYO Sports
8th Grade Class
SUPPORT US
Annual Fund
EITC Program
Fundraising
Volunteer
Logo Wear
60th ANNIVERSARY
EMPLOYMENT
|||
Parents
Calendar
Alumni
Church
PARENTS
CALENDAR
ALUMNI
CHURCH
HOME
Facebook
Custom Social Media
Phone
Search
Search
ABOUT US
About SSJ & Mission
Annual Report
Faculty and Staff
Little Explorers Preschool
School Board
School Security
History
Archdiocese of Philadelphia
ADMISSIONS
Request Information or Tour
Apply Now
Continuous Enrollment
Financial Aid
Tuition Payments and Scrip
CARES (Before & After School Care)
Testimonials
FAQs
ACADEMICS
Academic Overview
Teachers & Classrooms
Academic Support
Academic Enrichment
Specials
ACTIVITIES
Explorers Summer Camps
SSJ Theatre Jr. Fall Musical
Spring Musical
Student Activities & Clubs
Service Opportunities
CYO Sports
8th Grade Class
SUPPORT US
Annual Fund
EITC Program
Fundraising
Volunteer
Logo Wear
60th ANNIVERSARY
EMPLOYMENT
CARES PROGRAM
Health Emergency Information Form
ADMISSIONS
Request Information or Tour
Apply Now
Continuous Enrollment
Financial Aid
Tuition Payments and Scrip
CARES (Before & After School Care)
CARES ON LINE REGISTRATION FORM
Health Emergency Information Form
Testimonials
FAQs
The maximum number of form submissions has been reached. This form is currently not available.
PLEASE COMPLETE AND SUBMIT A SEPARATE FORM FOR EACH CHILD.
CHILD'S NAME:
First Name
REQUIRED
Please fill out this field.
Please enter valid data.
Last Name
REQUIRED
Please fill out this field.
Please enter valid data.
Date of Birth:
REQUIRED
Please fill out this field.
Please enter valid data.
Grade:
REQUIRED
Please fill out this field.
Please enter valid data.
Room #:
Please enter valid data.
Address Line 1:
REQUIRED
Please fill out this field.
Please enter valid data.
Address Line 2:
Please enter valid data.
City
REQUIRED
Please fill out this field.
Please enter valid data.
State
REQUIRED
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Please fill out this field.
Zip
REQUIRED
Please fill out this field.
Please enter a zip code.
Email
REQUIRED
Please fill out this field.
Please enter an email address.
Home Phone #:
Please enter valid data.
Mother's Cell #:
REQUIRED
Please fill out this field.
Please enter valid data.
Mother's Work #:
Please enter valid data.
Father's Cell #
REQUIRED
Please fill out this field.
Please enter valid data.
Father's Work #:
Please enter valid data.
EMERGENCY CONTACTS
In the event of apparent serious illness, accident, or when I cannot be reached, I wish one of the following to be notified by telephone. They may also release and pick up my child/children from the CARES program.
CONTACT #1 (FIRST/LAST NAME)
REQUIRED
Please fill out this field.
Please enter valid data.
Phone Number
REQUIRED
Maximum 20 characters
Please fill out this field.
Please enter a phone number.
CONTACT #2 (FIRST/LAST NAME)
Please enter valid data.
Phone Number
Maximum 20 characters
Please enter a phone number.
CONTACT #3 (FIRST/LAST NAME)
Please enter valid data.
Phone Number
Maximum 20 characters
Please enter a phone number.
Please list any special health information such as diabetes, epilepsy, allergies, eye or ear problems, or any other chronic condition:
Please enter valid data.
Please list any medications your child is taking:
Please enter valid data.
Name of Doctor:
REQUIRED
Please fill out this field.
Please enter valid data.
Phone Number
REQUIRED
Maximum 20 characters
Please fill out this field.
Please enter a phone number.
PLEASE NOTE:
Any medication that must be given during the program must be accompanied by a note from the Doctor, properly labeled and given to the Program Director. If personnel are unable to contact any of the authorized adults listed on this form, the Program Director may make the necessary decisions in any emergency at no expense or liability to Saints Simon and Jude.
Name of medication and instructions on medication administration:
Please check one of the following boxes:
I give permission to administer 25 mg Benadryl by mouth if an allergic reaction should occur:
I DO NOT give permission to administer 25 mg Benadryl by mouth if an allergic reaction should occur:
Please let us know if you have any questions or comments:
THANK YOU FOR SUBMITTING THIS FORM!
Submit
This site is protected by reCAPTCHA and the Google
Privacy Policy
and
Terms of Service
apply.