Child's Name
Child's Name
Child's Birthdate *
Child's Birthdate
M / F
Child's Address
Child's Address
Ethnicity
Mother's Information
Mothers Name *
Mothers Name
Cell Phone
Cell Phone
Home Address *
Home Address
Work Address
Work Address
Work Phone Number
Work Phone Number
Father's Information
Cell Phone
Cell Phone
Home Address
Home Address
Work Address
Work Address
Work Phone
Work Phone
Marital Status *
Identify Legal Guardian *
If Other, Indicate Name
If Other, Indicate Name
Emergency Contacts to call other than parents (minimum of two) in case of necessity, and are authorized to receive child:
Emergency Contact #1 *
Emergency Contact #1
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Address
Address
Emergency Contact #2 *
Emergency Contact #2
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Address
Address
Emergency Contact #3
Emergency Contact #3
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Address
Address
Child's Physician
Child's Physician
Phone
Phone
Has your child attended school before?
Date
Date
Has your child ever been separated from both parents?
If yes, who cared for the child?
If yes, who cared for the child?
Other children in family?
If parents are divorced/separated, does he/she see the child?
If yes, does he/she see the child:
Parents, please tell us how you heard of our school: *
I hereby give my consent and authorize the Jolly Fun House Playschool, located at 7559 W. Addison Street, Chicago, IL 60634 as long as my child, my children, or children under my guardianship are enrolled therein, to first contact emergency medical services or to take such children to the hospital or any medical center, for emergency medical care or treatment in the case of sudden illness or accident. I agree to bear the cost, if any, of such necessary emergency care. I hereby give permission for the above named child to be taken from the school premises for extra activities such as field trips, picnics, walks, etc. I also give permission for my child to travel by school approved transportation. I understand that the school will take candid pictures/videos of all children, and email me information unless requested otherwise. The pictures/videos will be incorporated into our annual music concert, and can be used for all digital, and print advertising purposes. I have provided the school with a valid email address, as the school will email the documents to parents. I hereby give permission to Jolly Fun House Playschool to email all communication and paperwork to the email provided. I understand the school reserves the right to discontinue children at any time, at the discretion of the administration. I have read and understood Jolly Fun House Playschool’s policies and regulations. I am aware they are posted on the school website, and agree to comply with them.
I have received the parents handbook: *
Parent or Guardian Digital Signature *
Parent or Guardian Digital Signature
Date
Date
Date of Admittance
Date of Admittance
Date of Discontinuance
Date of Discontinuance
Wait List
Tentative Start Date
Tentative Start Date
IDHS
IDHS Approval Date
IDHS Approval Date
IDHS Expiration Date
IDHS Expiration Date
Trained or Untrained
$
$
$
$
Date Received
Date Received

Chicago

7559 W Addison St
Chicago, Illinois

773.637.6115