ELA Afterschool Program- 9th-12th
Student application for Knowledge Quest High School Academy program.
All school information should be entered regarding the 2022-2023 school year.
Participant Name: *
Suffix (Jr., etc.)
Knowledge Quest History
Please provide details about the child and the child's family's previous experiences with KQ programming.
Returning student? * Indicate whether previous participant in KQ programming Returning Student New Student If yes, when? * Select most recent participation term Summer 2022 Afterschool- 2021-2022 Summer- 2021 Afterschool- 2020-2021 Summer- 2020 Afterschool- 2019-2020 Summer- 2019 Afterschool- 2018-2019 Summer- 2018 Afterschool- 2017-2018 Prior to 2018 Have sibling(s) ever been in KQ programming? * Select whether sibling(s) participated past or present Yes No, Sibling(s) newly registering now If yes, when? * Select best fit for when sibling(s) attend(ed) Sibling(s) attend currently Sibling(s) attended in past (not current) Sibling(s) enrolling now (first time) Participant Information
Provide information about your child. Please check to ensure accuracy!
Date of Birth: * Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Gender: * Race(s) & Ethnicity: * Any Legal Alerts? * Are there alerts KQ needs to be aware of for child's safety? Yes No Home Address:
* Length of Residence * Select length of time at this residence. Less that 3 months 3 to 6 months 6 to 12 months 1-2 years 3-5 years More than 5 years Student Cell? * Select yes if child has a separate cell number. Yes No Parent or Guardian Information
Provide information for the primary caregiver for this child.
Guardian Name: *
Relationship: * Select relationship to child. Mother (biological or adopted) Father (biological or adopted) Grandparent Stepmother Stepfather Aunt or Uncle Other Is this person completing the form? * If no, who is?
Guardian Address *
Same as child
Authorized Pickup? * Designate whether this person is authorized to pick up. Yes No Primary Contact? * Is this the primary contact for dismissal & emergencies? Yes No Will s/he be primary contact? Legal Guardian? * Does this person have legal custody? Yes No Other Hidden Is this the primary parent (legal custody)? If no, who is the child's Legal Guardian? *
Parent Guardian Additional Information
Please provide demographic information about the parent/guardian listed above.
Relationship Status * Select current relationship status. Single In a relationship Married Divorced Other Hidden Relationship Status: Education Level: * Select highest level of education completed. Some High School High School diploma/GED Some college or further education 2 year college (Assoc. Degree) 4-year college (BS/BA Degree) Masters Degree Advanced Graduate Degree Other Employment Status: * Work Address (Optional)
Add Parent/Guardian? * Do you want to add information for a second adult? Yes No Hidden Add additional Parent/Guardian? Parent/Guardian Information #2
Optional: contact information for a second parent or guardian.
Does this person live with child? * Indicate if currently residing in same home as child. Yes No Sometimes Address *
Same as child
Authorized Pickup? * Designate whether this person is authorized to pick up. Yes No Hidden Authorized to Pick-Up? Education Level: * Indicate highest level of education completed. Some High School High School diploma/GED Some college or further education 2 year college (Assoc. Degree) 4-year college (BS/BA Degree) Masters Degree Advanced Graduate Degree Other Employment Status: * School Information
Please provide information about the school and grade that this participant will be attending in the fall of 2022.
Participant's School: * Select school Soulsville Charter School Booker T. Washington (BTW) Hollis F. Price Other
2022-2023 Grade Level: * Select grade 9th 10th 11th 12th Student ID Number: * Select whether you can provide the District Issued ID number. Yes No I can provide at a later date. Hidden Student ID Number: Does student receive additional Educational Programs & Services through school? * School Information Consent * I have read and agree to the School Information Consent statement below.
Knowledge Quest has my permission to obtain records and access to other educational information from the school where my child attends, as indicated above.
Please provide accurate demographic information about the household. This information is for data purposes and will not be shared.
Type of Residence * Rehousing or Homelessness in past 18 months? * How many adults (anyone 18+) live in household with child? * How many children (anyone under 18) live in household? Including this child? * Members of Household *
Select the family members who currently live with this child.
How many sisters live with child? * How many brothers live with child? * Number of adults in home currently employed Full Time: * Number of adults in home currently employed Part Time: * Number of adults in home currently Not Working: * Hidden How many adults living in home are working... Number of adults in home graduated high school? * List all siblings. Add row for each new sibling. * Annual Household Income: * Please estimate total household income for a year Under $27,449 $27,450- $43,899 $43,900 or more Hidden Annual Household Income Range: Have utilities been disconnected in the past 18 months? * Participant 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.) * If yes, list conditions/concerns. Add a new row for each. Does participant have a regular Primary Physician or Pediatrician? * Name of Physician:
Dr. Dr. Mr. Ms.
Emergency Treatment Authorization * 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.
Dismissal Information What is the participant's mode of transportation? * Hidden I give my child permission to sign-in and out and/or to be released as a walker. Independent Walker Release * I consent to the statement below.
My child has permission to sign himself or herself in and out of KQ programming. I give consent for my child to be released as an independent walker and leave at the end of programming without adult supervision. Knowledge Quest will not be responsible for my child when they leave the program.
MODE OF TRANSPORTATION: By indicating that your child is a walker you agree to indemnify and 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 said mode of transportation. 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. List who child will walk home with: *
Add row for each
List those Authorized for Pick Up (add row for each): * 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): *
Add row for each
Consents & Authorization
Please read the statements below carefully.
Media Release * 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.
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 * 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 * 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.