ELA Afterschool Registration 23-24(PK-8) ELA Afterschool Application- PK-8 (2023-2024) Knowledge Quest- Extended Learning Academies- Afterschool Programming Register Pre-Kindergarten-8th Grade students for daily afterschool programming in Knowledge Quest's Extended Learning Academies. "*" indicates required fields ELA Afterschool Student ApplicationPlease fill out this application carefully and double check to ensure that all information provided is accurate and correct (including spelling).KQ Campus:*Select program site based on grade level.Main Campus- K-2nd (Jennette)College Park- 3rd-8thCollege Park- PKGaston Park- 2nd-5th (COSLA, Ida B Wells, LaRose Only)Participant's Name* First MI Last Optional: Jr., etc. Family History with Knowledge QuestPlease provide all information about previous enrollment or participation that this child or other family members have had with Knowledge Quest programming.Returning student?*Has child ever enrolled in KQ programming before?Returning StudentNew StudentIf yes, when?*Select most recent participation termSummer 2022Afterschool- 2021-2022Summer- 2021Afterschool 2020-2021Summer- 2020Afterschool- prior to 2020Summer- prior to 2020OtherHave sibling(s) enrolled in KQ?*Select whether sibling(s) have ever enrolled- past or presentYesNoSibling(s) newly registering nowWhen did siblings attend?*Select best fit for when sibling(s) attend(ed)Sibling(s) attend currentlySibling(s) attended in past (not current)Sibling(s) enrolling now (first time)Participant InformationProvide information about your child. Please check to ensure accuracy!Name* First Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender:* 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?*Are there alerts KQ needs to be aware of for child's safety?YesNoIf yes, explain:Home Address:* Street Address Apartment # City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Length of Residence*Select length of time at this residence.Less that 3 months3 to 6 months6 to 12 months1-2 years3-5 yearsMore than 5 yearsStudent Cell?*Select yes if child has a separate cell number.YesNoIf yes, provide number:Parent or Guardian InformationProvide information for the primary caregiver for this child.Guardian Name:* First Last Relationship:*Select relationship to child.Mother (biological or adopted)Father (biological or adopted)GrandparentStepmotherStepfatherAunt or UncleOtherIs this person completing the form?* Yes No Yes, with assistance. If no, who is? First Last Guardian Address* Same as child Street Address Apartment # City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone Number:*Email: Authorized Pick Up?*Designate whether this person has permission to pick up.YesNoPrimary Contact?*Is this the primary contact for dismissal & emergencies?YesNoLegal Guardian?*Does this person have legal custody?YesNoOtherIf no, who is the child's Legal Guardian?* First Last Parent Guardian Additional InformationPlease provide demographic information about the parent/guardian listed above. Relationship Status:*Select current relationship status.SingleIn a relationshipMarriedDivorcedWidowedOtherEducation Level:*Select highest level of education completedSome High SchoolHigh School diploma/GEDSome college or further education2 year college (Assoc. Degree)4-year college (BS/BA Degree)Masters DegreeAdvanced Graduate DegreeOtherEmployment 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Add Parent/ Guardian?*Do you want to add information for another adult?YesNoParent/Guardian Information #2Optional: contact information for a second parent or guardian. Parent/Guardian Name:* First Last Relationship:*Select relationship to child.Father (biological or adopted)Mother (biological or adopted)GrandparentStepmotherStepfatherAunt or UncleOtherPhone Number:*Email: Does this person live with child?*Indicate if currently residing in same home as child.YesNoSometimesAddress* Same as child Street Address Apartment # City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Authorized Pick Up?*Designate whether this person has permission to pick up.YesNoEducation Level:*Indicate highest level of education completed.Some High SchoolHigh School diploma/GEDSome college or further education2 year college (Assoc. Degree)4-year college (BS/BA Degree)Masters DegreeAdvanced Graduate DegreeOtherEmployment Status:* Full-Time Part-Time Unemployed Not working School InformationPlease provide information about the school and grade this child will be attending in the fall of 2022. Participant's School:*Select SchoolA. B. Hill ElementaryAlcy ElementaryBelieve Memphis AcademyBelle Forest ElementaryBellevue MiddleBethel Grove ElementaryBinghampton Christian AcademyBooker T. Washington (BTW)Bruce ElementaryCaldwell-GuthrieChickasaw Middle SchoolCircles of Success (COSLA)Cornerstone Prep- DenverCromwell ElementaryCummings SchoolDouble Tree ElementaryDowntown ElementaryFlorida Kanses (Memphis Scholars)Ford Road ElementaryFox Meadows ElementaryGrizzlies Prep AcademyHumes Middle SchoolIda B. Wells ElementaryJackson ElementaryKIPP Memphis Collegiate ElementaryKIPP Memphis Collegiate MiddleLaRose ElementaryLibertas School of MemphisMASEMemphis Delta Prep (MDP)Robert R Church ElementaryRozelle ElementaryScenic Hills ElementarySherwood ElementarySoulsville Charter SchoolVision PrepWhitehaven ElementaryUndecidedHomeschoolOther If Other, what school?* Current Grade Level:*Select gradePre-KKindergarten1st2nd3rd4th5th6th7th8thStudent ID Number:*Select whether you can provide the District Issue IDYesNoI will provide at a later dateStudent 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 InformationPlease 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 No How many adults (anyone 18+) live in household with child?*Please enter a number from 1 to 15.How many children (anyone under 18) live in household? Including this child.*Please enter a number from 1 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 brothers live with child?*Please enter a number from 0 to 15.How many sisters live with child?*Please enter a number from 0 to 15.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.Number of adults in home graduated high school?*Please enter a number from 0 to 15.List all siblings. Add row for each new sibling.*First NameLast NameBirthday (mm/dd/yyyy) Add RemoveAnnual Household Income:*Please estimate total household income for a yearUnder $27,449$27,450- $43,899$43,900 or moreHave utilities been disconnected in the past 18 months?* Yes No Participant Medical InformationIt 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 No If yes, list conditions/concerns. Add a new row for each. Add RemoveDoes 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 Dr.Dr.Mr.Ms. 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 InformationWhat is the child's mode of transportation?* Independent Walker Pickup by designated party 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 RemoveAdd row for eachList those Authorized for Pick Up (add row for each):*First NameLast NamePhoneRelationship Add RemoveEmergency ContactsPlease 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 NameLast NameRelationshipPhone Add RemoveAdd row for eachConsents & AuthorizationPlease 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 affiliatesI 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* SignatureBy 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. Name First Last Previous School Year- Final Report CardAccepted file types: jpg, pdf, Max. file size: 100 MB.Please upload a PDF or picture (must be clear and show entire page) of the student's final report card from last school year (2022-2023). This must be submitted before your student can begin attending programming. Who is your Family Coach?*Efua ColemanLavada HermanLatisha BlackburnReginia QuinonesPreet KaurJennifer CrenshawI don't have a Family Coach yet.https://s1k.4b6.myftpupload.com/programs/family-stability-initiative/register/ Fill our your intake form to be assigned a Family Coachhttps://s1k.4b6.myftpupload.com/programs/family-stability-initiative/register/ Thank you for being a Knowledge Quest member! Δ