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Sick Pay Form

If you are calling out sick for a scheduled shift for any reason, please complete the information below in full and one of our HR Associates may contact you if we have any questions. Some fields and responses are optional.

Please list your full name
What is your employee number? (can be found on paychecks) If you don't know, put UNK
Mobile phone or best number to reach you
(Please check all that apply. Work-related injuries must be called into HR immediately.)
Please check ALL that apply below to the missed work time being reported on this form. If you are including missed work for two separate families and the reasons were different, please describe that in each family's comments. If you are missing work for more than 2 families, please fill out another form. If you would like to see if you have COVID-19 supplemental sick pay available to apply to your absence, please select reason(s) for absence below AND also select the last box under this section.
Please upload any documents related to test results or vaccine proof here, if required, or you can email to
Name of the child/adult with whom I was scheduled to work
MUST list dates and hours scheduled and reason care was cancelled (eg. Monday 10/25/2021 from 5pm-8pm=3 hours. I was too ill to work.) You can put multiple dates/times if that applies.
Name of the child/adult with whom I was scheduled to work
See Comments #1 section above for directions

Please login to Paylocity, our payroll system, to view your current sick pay balance.
Covid Supplemental Sick Pay was reinstated 2/19/2022. If you have any questions, contact Rosy Lopez, HR Manager, at (805) 384-0983 x862 or

For security verification, please enter any random two digit number. For example: 65
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