Registration Form

Registration Form

Starting: June 4th to Nov 20th, 2026
Every Thursday and Second Saturday of the month

Time: 10:00 AM to 1:00 PM

Address: 3750 N. Neva Ave - Chicago, IL 60634

For more information, please contact Tanya Jean-Baptiste at (708) 228-8498 or email us at tbaptiste@revivalhousecc.com. Thank you!
Parent/Guardian Contact Information
Relationship to the Child*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Children's information
1. Child's Name*

First NameMiddle NameLast Name
Age*
MaleFemale
Birth Date*

MonthDayYear
List any food allergies or any food restrictions
2. Child's Name

First NameMiddle NameLast Name
Age
MaleFemale
Birth Date

MonthDayYear
List any food allergies or any food restrictions
Parents Name if Different from Guardian or above

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name:

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: