Apply for Pre-K (2023-2024)

Early Childhood Academy (Pre-K) Application 2023-2024

Step 1 of 7

14%

This application is for the Full Day Pre-K for 2, 3, and 4-year-olds only.

Did your child turn 4 years of age by August 15 2023?(Required)

Did your child turn 3 years of age by August 15 2023?(Required)

Did your child turn 2 years of age by August 15 2023?(Required)

Uh Oh! Your child is not eligible for the Early Childhood Academy this year.

Would you like to notified when your child is eligible?(Required)

Child's Name(Required)

First Last

Child's DOB(Required)

MM slash DD slash YYYY

Parent's Contact Information(Required)

First Last

Phone(Required)

Email(Required)

1.) CHILD'S INFORMATION

Provide information about your child. Please check to ensure accuracy!

Student's Name(Required)

First MI Last Suffix (Jr., etc.)

Date of Birth:(Required)

Age:(Required)

Please enter a number from 1 to 7.

Gender:(Required)

Male

Female

Other

Prefer not to answer

Race(s) & Ethnicity:(Required)

Black or African American

White

Asian

Native American

Hispanic or Latino

Prefer not to answer

Are you enrolling a second child?(Required)

Yes

Student's #2's Name:(Required)

First MI Last Suffix (Jr., etc.)

Student's #2's Date of Birth:(Required)

Student's #2's Age:(Required)

Please enter a number from 4 to 19.

Student's #2's Gender:(Required)

Male

Female

Other

Prefer not to answer

Student's #2's Race(s) & Ethnicity:(Required)

Black or African American

White

Asian

Native American

Hispanic or Latino

Prefer not to answer

Are you enrolling a third child?(Required)

Yes

Student's #3's Name:(Required)

First MI Last Suffix (Jr., etc.)

Student's #3's Date of Birth:(Required)

Student's #3's Age:

Please enter a number from 4 to 19.

Student's #3's Race(s) & Ethnicity:(Required)

Black or African American

White

Asian

Native American

Hispanic or Latino

Prefer not to answer

Student's #3's Gender:(Required)

Male

Female

Other

Prefer not to answer

Home Address:(Required)

Street Address Apartment # City State ZIP Code

Length of Residence(Required)

Any Legal Alerts?(Required)

If yes, explain:

2.) Parent or Guardian Information

Provide information for the primary caregiver for this child.

Guardian Name:(Required)

First Last

Phone #:(Required)

Email:(Required)

Relationship:(Required)

Is this person completing the form?(Required)

Yes

If no, who is?

First Last

Guardian Address(Required)

Same as child

Street Address Apartment # City State ZIP Code

Contact Information

Authorized Pick Up?(Required)

Primary Contact?(Required)

Legal Guardian?(Required)

If no, who is the child's Legal Guardian?(Required)

First Last

Parent Guardian Additional Information

Please provide demographic information about the parent/guardian listed above.

Relationship Status:(Required)

Education Level:(Required)

Employment Status:(Required)

Full-Time

Part-Time

Unemployed

Not working

Employer Name:(Required)

Job Title or Position:(Required)

Work Phone:(Required)

Work Address (Optional)(Required)

Street Address Address Line 2 City State ZIP Code

Add Parent/ Guardian?(Required)

Parent/Guardian Information #2

Optional: contact information for a second parent or guardian.

Parent/Guardian Name:(Required)

First Last

Relationship:(Required)

Phone Number:(Required)

Email:(Required)

Does this person live with child?(Required)

Address(Required)

Same as child

Street Address Apartment # City State ZIP Code

Authorized Pick Up?(Required)

Education Level:(Required)

Employment Status:(Required)

Full-Time

Part-Time

Unemployed

Not working

3.) Household Information

Please provide accurate demographic information about the household. This information is for data purposes and will not be shared.

Type of Residence(Required)

Apartment

House

Other

Rehousing or Homelessness in past 18 months?(Required)

Yes

How many adults (anyone 18+) live in household with child?(Required)

Please enter a number from 1 to 15.

How many children (anyone under 18) live in household? Including this child.(Required)

Please enter a number from 1 to 15.

Members of Household(Required)

Mother

Father

Grandparent(s)

Step-parent(s)

Guardian(s)

Foster Parent(s)

Brother(s)

Sister(s)

Cousin(s)

Aunt(s)

Uncle(s)

Other

Select the family members who currently live with this child.

How many brothers live with child?(Required)

Please enter a number from 0 to 15.

How many sisters live with child?(Required)

Please enter a number from 0 to 15.

Number of adults in home currently employed Full Time:(Required)

Please enter a number from 0 to 15.

Number of adults in home currently employed Part Time:(Required)

Please enter a number from 0 to 15.

Number of adults in home currently Not Working:(Required)

Please enter a number from 0 to 15.

Number of adults in home graduated high school?(Required)

Please enter a number from 0 to 15.

List all siblings. Add row for each new sibling.(Required)

First Name

Last Name

Birthday (mm/dd/yyyy)

Annual Household Income:(Required)

Have utilities been disconnected in the past 18 months?(Required)

Yes

4.) Student's Medical Information

It is the responsibility of the Parent or Guardian to provide Knowledge Quest with specific emergency procedures.

Are there any medical conditions or specifications? (allergies, medical issues, food requirements, etc.)(Required)

Yes

If yes, list conditions/concerns. Add a new row for each.

Does participant have a regular Primary Physician or Pediatrician?(Required)

Yes

Yes, but I cannot provide contact information at this time

No, there is no pediatrician or primary physician

Name of Physician:(Required)

Prefix First Last

Physician Phone:(Required)

Insurance Name:(Required)

Policy #:(Required)

Hospital Affiliation:(Required)

Emergency Treatment Authorization(Required)

I have read and consent to the Emergency Treatment Policy below.

By checking this box, I am indicating consent and authorizing Knowledge Quest to provide first aid and/or to secure medical care in the case of an emergency for the child named on this application. I authorize the physician or hospital I provided in this section to treat my child in the event of an emergency. If this physician or hospital is not available or cannot be reached, I consent to care and treatment being administered by another licensed physician or treatment facility. I realize that I will be responsible for any costs of treatment. I will not hold Knowledge Quest or any of its staff or affiliates liable.

Child Relase Form

List those Authorized for Pick Up (add row for each):(Required)

First Name

Last Name

Phone

Relationship

4.) Emergency Contacts

Please provide contact information for at least one additional adult (other than parent/guardians listed above) to contact in case of emergency. Add additional lines for each contact you wish to add.

Additional Emergency Contact(s):(Required)

First Name

Last Name

Relationship

Phone

Add row for each

5.) Consents & Authorization

Please read the statements below carefully.

Acknowledgement of Consent(Required)

I consent to the statement below.

I give consent for the individuals I’ve indicated on this application under “Approved for Release” can sign my child in and out of KQ programming. I acknowledge Knowledge Quest will not be responsible for my child when they leave the program.

I agree to not hold Knowledge Quest, its employees, board of directors, and/affiliates harmless of any such claim, demand, cause of action, or any legal or equitable action arising out of relating to your child/children in the said release. As parent/legal guardian. I waive any rights to litigation regarding accident, injury, and/or expiry after my child has been dismissed from Knowledge Quest.

Media Release(Required)

I agree to the above policies.

I grant permission to Knowledge Quest to use my child’s image may be used by Knowledge Quest. This consent includes the purposes of promoting the Extended Learning Academy, Knowledge Quest, and other related programs in various material and forms of media.

Statement of Consent for Activities(Required)

I agree to the privacy policy.

I give my permission for the child named on this application to engage in all off and on campus learning, recreational, and field trip experiences provided through Knowledge Quest programming during and after standard operation hours.

I agree to release Knowledge Quest, its employees, and affiliates from liability for injuries or loss of life resulting from or occurring during these activities as a result of regular program operations.

Statement of Indemnification(Required)

I agree to the statement below and to hold harmless Knowledge Quest and its affiliates

I hereby release and hold harmless Knowledge Quest, its employees, board of directors, and/or affiliates from any liability which may arise out of or in connection with my child/children’s traveling as a part of Knowledge Quest, including, but not limited to potential claims, demands and causes or action for compensatory or punitive damages, attorney fees, costs, and other legal or equitable relief of any other legal or equitable relief of any kind, for injuries and damages, and the consequences thereof, whether known or unknown, foreseen or unforeseen, arising out of or resulting from Knowledge Quest, its staff, its affiliates or representatives.

I further agree to indemnify and hold Knowledge Quest, its employees, board of directors, and/or affiliates harmless of any such claim, demand, cause of action or any legal or equitable action arising out of relating to my child(ren) in said event. As parent/legal guardian, I waive any rights to litigation regarding accident, injury, and/or expiry through my child’s participation in the program.

Statement of Confirmation(Required)

Signature

By checking this box I am confirming that I have completed this application to the best of my ability in all honesty. I am the parent/legal guardian of the child listed above. I give my permission for his/her participation in Knowledge Quest programming.

Documentation requirements listed below(Required)

I agree to provide the documents.

The following documents will be required for the final step in the enrollment process: Parent’s Photo Identification Parent’s Proof of Income (3 most recent check stubs, 2021 W-2/Tax Return, Proof of Families First, SSI Disability or Child Support if Applicable) and proof of income for all adult members of the household 2 Documents for Parent’s Proof of Address (MLGW Bill, Telephone Bill, Lease, or Mortgage in Parent’s Name) Certified Copy of Child’s Birth Certificate Certificate of Child’s Immunization with Current Physical Exam (Within the past 12 months) Child’s Health Insurance Card Child’s Social Security Card Copy of IEP (If applicable) **Child must be present to be screened during the enrollment process If you have any questions, please call (901) 207-3694

6.) Knowledge Quest History

Please provide details about the child and the child’s family’s previous experiences with KQ programming.

Have sibling(s) ever been in KQ programming?(Required)

If yes, when?(Required)

Who is your Family Coach?

Fill out your Intake form to be assigned a Family Coach.

https://www.knowledgequest.org/programs/family-stability-initiative/register/

Thank you for being a Knowledge Quest Member!

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Early Childhood Academy (Pre-K) Application 2023-2024

Step 1 of 7

14%

This application is for the Full Day Pre-K for 2, 3, and 4-year-olds only.

Did your child turn 4 years of age by August 15 2023?(Required)

Did your child turn 3 years of age by August 15 2023?(Required)

Did your child turn 2 years of age by August 15 2023?(Required)

Uh Oh! Your child is not eligible for the Early Childhood Academy this year.

Would you like to notified when your child is eligible?(Required)

Child's Name(Required)

First Last

Child's DOB(Required)

MM slash DD slash YYYY

Parent's Contact Information(Required)

First Last

Phone(Required)

Email(Required)

1.) CHILD'S INFORMATION

Provide information about your child. Please check to ensure accuracy!

Student's Name(Required)

First MI Last Suffix (Jr., etc.)

Date of Birth:(Required)

Age:(Required)

Please enter a number from 1 to 7.

Gender:(Required)

Male

Female

Other

Prefer not to answer

Race(s) & Ethnicity:(Required)

Black or African American

White

Asian

Native American

Hispanic or Latino

Prefer not to answer

Are you enrolling a second child?(Required)

Yes

Student's #2's Name:(Required)

First MI Last Suffix (Jr., etc.)

Student's #2's Date of Birth:(Required)

Student's #2's Age:(Required)

Please enter a number from 4 to 19.

Student's #2's Gender:(Required)

Male

Female

Other

Prefer not to answer

Student's #2's Race(s) & Ethnicity:(Required)

Black or African American

White

Asian

Native American

Hispanic or Latino

Prefer not to answer

Are you enrolling a third child?(Required)

Yes

Student's #3's Name:(Required)

First MI Last Suffix (Jr., etc.)

Student's #3's Date of Birth:(Required)

Student's #3's Age:

Please enter a number from 4 to 19.

Student's #3's Race(s) & Ethnicity:(Required)

Black or African American

White

Asian

Native American

Hispanic or Latino

Prefer not to answer

Student's #3's Gender:(Required)

Male

Female

Other

Prefer not to answer

Home Address:(Required)

Street Address Apartment # City State ZIP Code

Length of Residence(Required)

Any Legal Alerts?(Required)

If yes, explain:

2.) Parent or Guardian Information

Provide information for the primary caregiver for this child.

Guardian Name:(Required)

First Last

Phone #:(Required)

Email:(Required)

Relationship:(Required)

Is this person completing the form?(Required)

Yes

If no, who is?

First Last

Guardian Address(Required)

Same as child

Street Address Apartment # City State ZIP Code

Contact Information

Authorized Pick Up?(Required)

Primary Contact?(Required)

Legal Guardian?(Required)

If no, who is the child's Legal Guardian?(Required)

First Last

Parent Guardian Additional Information

Please provide demographic information about the parent/guardian listed above.

Relationship Status:(Required)

Education Level:(Required)

Employment Status:(Required)

Full-Time

Part-Time

Unemployed

Not working

Employer Name:(Required)

Job Title or Position:(Required)

Work Phone:(Required)

Work Address (Optional)(Required)

Street Address Address Line 2 City State ZIP Code

Add Parent/ Guardian?(Required)

Parent/Guardian Information #2

Optional: contact information for a second parent or guardian.

Parent/Guardian Name:(Required)

First Last

Relationship:(Required)

Phone Number:(Required)

Email:(Required)

Does this person live with child?(Required)

Address(Required)

Same as child

Street Address Apartment # City State ZIP Code

Authorized Pick Up?(Required)

Education Level:(Required)

Employment Status:(Required)

Full-Time

Part-Time

Unemployed

Not working

3.) Household Information

Please provide accurate demographic information about the household. This information is for data purposes and will not be shared.

Type of Residence(Required)

Apartment

House

Other

Rehousing or Homelessness in past 18 months?(Required)

Yes

How many adults (anyone 18+) live in household with child?(Required)

Please enter a number from 1 to 15.

How many children (anyone under 18) live in household? Including this child.(Required)

Please enter a number from 1 to 15.

Members of Household(Required)

Mother

Father

Grandparent(s)

Step-parent(s)

Guardian(s)

Foster Parent(s)

Brother(s)

Sister(s)

Cousin(s)

Aunt(s)

Uncle(s)

Other

Select the family members who currently live with this child.

How many brothers live with child?(Required)

Please enter a number from 0 to 15.

How many sisters live with child?(Required)

Please enter a number from 0 to 15.

Number of adults in home currently employed Full Time:(Required)

Please enter a number from 0 to 15.

Number of adults in home currently employed Part Time:(Required)

Please enter a number from 0 to 15.

Number of adults in home currently Not Working:(Required)

Please enter a number from 0 to 15.

Number of adults in home graduated high school?(Required)

Please enter a number from 0 to 15.

List all siblings. Add row for each new sibling.(Required)

First Name

Last Name

Birthday (mm/dd/yyyy)

Annual Household Income:(Required)

Have utilities been disconnected in the past 18 months?(Required)

Yes

4.) Student's Medical Information

It is the responsibility of the Parent or Guardian to provide Knowledge Quest with specific emergency procedures.

Are there any medical conditions or specifications? (allergies, medical issues, food requirements, etc.)(Required)

Yes

If yes, list conditions/concerns. Add a new row for each.

Does participant have a regular Primary Physician or Pediatrician?(Required)

Yes

Yes, but I cannot provide contact information at this time

No, there is no pediatrician or primary physician

Name of Physician:(Required)

Prefix First Last

Physician Phone:(Required)

Insurance Name:(Required)

Policy #:(Required)

Hospital Affiliation:(Required)

Emergency Treatment Authorization(Required)

I have read and consent to the Emergency Treatment Policy below.

Child Relase Form

List those Authorized for Pick Up (add row for each):(Required)

First Name

Last Name

Phone

Relationship

4.) Emergency Contacts

Please provide contact information for at least one additional adult (other than parent/guardians listed above) to contact in case of emergency. Add additional lines for each contact you wish to add.

Additional Emergency Contact(s):(Required)

First Name

Last Name

Relationship

Phone

Add row for each

5.) Consents & Authorization

Please read the statements below carefully.

Acknowledgement of Consent(Required)

I consent to the statement below.

Media Release(Required)

I agree to the above policies.

Statement of Consent for Activities(Required)

I agree to the privacy policy.

Statement of Indemnification(Required)

I agree to the statement below and to hold harmless Knowledge Quest and its affiliates

Statement of Confirmation(Required)

Signature

Documentation requirements listed below(Required)

I agree to provide the documents.

6.) Knowledge Quest History

Please provide details about the child and the child’s family’s previous experiences with KQ programming.

Have sibling(s) ever been in KQ programming?(Required)

If yes, when?(Required)

Who is your Family Coach?

Fill out your Intake form to be assigned a Family Coach.

https://www.knowledgequest.org/programs/family-stability-initiative/register/

Thank you for being a Knowledge Quest Member!

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