ELA Afterschool Application- 9th-12th (2023-2024)

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.)

Which program will you be particpating in? (Select all that all)

Best Buy Teen Tech Center

JUCA (Culinary Program)

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!

Name*

First Last

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:

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

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*

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:

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

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.

Who is your Family Coach?

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

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