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Select Page

ELA Afterschool Application- 9th-12th (2022-2023)

Knowledge Quest- Extended Learning Academies- Afterschool Programming Register 9th-12th grade students for daily afterschool programming in Knowledge Quest's Extended Learning Academies. Programming opportunities include activities with the Best Buy Teen Tech Center (BBTTC) and the Jay Uiberall Culinary Academy (JUCA).

"*" indicates required fields

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:*

Knowledge Quest History

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

Participant Information

Provide information about your child. Please check to ensure accuracy!
Date of Birth:*
Gender:*
Please enter a number from 4 to 19.
Race(s) & Ethnicity:*
Home Address:*

Parent or Guardian Information

Provide information for the primary caregiver for this child.
Guardian Name:*
Is this person completing the form?*
If no, who is?
Guardian Address*
Will s/he be primary contact?
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.
Hidden
Relationship Status:
Employment Status:*
Work Address (Optional)
Hidden
Add additional Parent/Guardian?

Parent/Guardian Information #2

Optional: contact information for a second parent or guardian.
Address*
Hidden
Authorized to Pick-Up?
Employment Status:*

School Information

Please provide information about the school and grade that this participant will be attending in the fall of 2022.
Hidden
Student ID Number:
Does student receive additional Educational Programs & Services through school?*
School Information Consent*
Knowledge Quest has my permission to obtain records and access to other educational information from the school where my child attends, as indicated above.

Household Information

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?*
Please enter a number from 0 to 15.
Please enter a number from 0 to 15.
Members of Household*
Select the family members who currently live with this child.
Please enter a number from 1 to 19.
Please enter a number from 1 to 10.
Please enter a number from 0 to 15.
Please enter a number from 0 to 15.
Please enter a number from 0 to 15.
Hidden
How many adults living in home are working...
Full-time
Part-time
Not Working
 
Please enter a number from 0 to 10.
List all siblings. Add row for each new sibling.*
First Name
Last Name
Birthday (mm/dd/yyyy)
 
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:
Emergency Treatment Authorization*
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*
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):*
First Name
Last Name
Phone
Relationship
 

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):*
First Name
Last Name
Relationship
Phone
 
Add row for each

Consents & Authorization

Please read the statements below carefully.
Media Release*
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*
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 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*
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.

ELA Afterschool Application- 9th-12th (2022-2023)

Knowledge Quest- Extended Learning Academies- Afterschool Programming Register 9th-12th grade students for daily afterschool programming in Knowledge Quest's Extended Learning Academies. Programming opportunities include activities with the Best Buy Teen Tech Center (BBTTC) and the Jay Uiberall Culinary Academy (JUCA).

"*" indicates required fields

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:*

Knowledge Quest History

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

Participant Information

Provide information about your child. Please check to ensure accuracy!
Date of Birth:*
Gender:*
Please enter a number from 4 to 19.
Race(s) & Ethnicity:*
Home Address:*

Parent or Guardian Information

Provide information for the primary caregiver for this child.
Guardian Name:*
Is this person completing the form?*
If no, who is?
Guardian Address*
Will s/he be primary contact?
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.
Hidden
Relationship Status:
Employment Status:*
Work Address (Optional)
Hidden
Add additional Parent/Guardian?

Parent/Guardian Information #2

Optional: contact information for a second parent or guardian.
Address*
Hidden
Authorized to Pick-Up?
Employment Status:*

School Information

Please provide information about the school and grade that this participant will be attending in the fall of 2022.
Hidden
Student ID Number:
Does student receive additional Educational Programs & Services through school?*
School Information Consent*
Knowledge Quest has my permission to obtain records and access to other educational information from the school where my child attends, as indicated above.

Household Information

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?*
Please enter a number from 0 to 15.
Please enter a number from 0 to 15.
Members of Household*
Select the family members who currently live with this child.
Please enter a number from 1 to 19.
Please enter a number from 1 to 10.
Please enter a number from 0 to 15.
Please enter a number from 0 to 15.
Please enter a number from 0 to 15.
Hidden
How many adults living in home are working...
Full-time
Part-time
Not Working
 
Please enter a number from 0 to 10.
List all siblings. Add row for each new sibling.*
First Name
Last Name
Birthday (mm/dd/yyyy)
 
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:
Emergency Treatment Authorization*
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*
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):*
First Name
Last Name
Phone
Relationship
 

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):*
First Name
Last Name
Relationship
Phone
 
Add row for each

Consents & Authorization

Please read the statements below carefully.
Media Release*
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*
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 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*
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.

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