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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 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 1/2/2023 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 expired 12/31/2022 in the state of California, with some exceptions for families receiving services in LA County.  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: 89
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