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:*

First Middle Initial Last 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?*

If yes, when?*

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

If yes, when?*

Participant Information

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

Date of Birth:*

Gender:*

Male

Female

Other

Prefer not to answer

Age:*

Please enter a number from 4 to 19.

Race(s) & Ethnicity:*

Black or African American

White

Asian

Native American

Hispanic or Latino

Prefer not to answer

Any Legal Alerts?*

If yes, explain:

Home Address:*

Street Address Apartment # City State ZIP Code

Length of Residence*

Student Cell?*

If yes, provide number:

Parent or Guardian Information

Provide information for the primary caregiver for this child.

Guardian Name:*

First Last

Relationship:*

Is this person completing the form?*

Yes

Yes, with assistance.

If no, who is?

First Last

Guardian Address*

Same as child

Street Address Apartment # City State ZIP Code

Phone Number:*

Email:

Authorized Pickup?*

Primary Contact?*

Will s/he be primary contact?

Yes

Legal Guardian?*

Hidden

Is this the primary parent (legal custody)?

Yes

Other

If no, who is the child's Legal Guardian?*

First Last

Parent Guardian Additional Information

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

Relationship Status*

Hidden

Relationship Status:

Single

In a relationship

Married

Divorced

Other

Education Level:*

Employment Status:*

Full-Time

Part-Time

Unemployed

Not working

Employer Name:*

Job Title or Position:

Work Phone:

Work Address (Optional)

Street Address Address Line 2 City State ZIP Code

Add Parent/Guardian?*

Hidden

Add additional Parent/Guardian?

Yes

Parent/Guardian Information #2

Optional: contact information for a second parent or guardian.

Phone Number:*

Does this person live with child?*

Address*

Same as child

Street Address Apartment # City State ZIP Code

Authorized Pickup?*

Hidden

Authorized to Pick-Up?

Yes

Education Level:*

Employment Status:*

Full-Time

Part-Time

Unemployed

Not working

School Information

Please provide information about the school and grade that this participant will be attending in the fall of 2022.

Participant's School:*

If Other, what school?

2022-2023 Grade Level:*

Student ID Number:*

Hidden

Student ID Number:

Yes

Will provide at later date

Student ID #:

Does student receive additional Educational Programs & Services through school?*

504 (Behavior Plan)

IEP

Special Education

Other

No education services in place

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.

Household Information

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

Type of Residence*

Apartment

House

Other

Rehousing or Homelessness in past 18 months?*

Yes

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

Please enter a number from 0 to 15.

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

Please enter a number from 0 to 15.

Members of Household*

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 sisters live with child?*

Please enter a number from 1 to 19.

How many brothers live with child?*

Please enter a number from 1 to 10.

Number of adults in home currently employed Full Time:*

Please enter a number from 0 to 15.

Number of adults in home currently employed Part Time:*

Please enter a number from 0 to 15.

Number of adults in home currently Not Working:*

Please enter a number from 0 to 15.

Hidden

How many adults living in home are working...

Full-time

Part-time

Not Working

Number of adults in home graduated high school?*

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)

Annual Household Income:*

Hidden

Annual Household Income Range:

Under $27,449

$27,450- $43,918

$43,919 or More

Have utilities been disconnected in the past 18 months?*

Yes

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.)*

Yes

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

Does participant have a regular Primary Physician or Pediatrician?*

Yes

Yes, but I cannot provide contact information at this time

No, there is no pediatrician or primary physician

Name of Physician:

Prefix First Last

Physician Phone:

Insurance Name:

Policy #:

Hospital Affiliation:

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?*

Independent Walker

Pickup by designated party

Hidden

I give my child permission to sign-in and out and/or to be released as a walker.

Yes

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):*

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 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*

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*

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.