Early Childhood Academy (Pre-K) Application 2024-2025 Register your rising 2, 3 & 4-year old Pre-K students by completing this form. Step 1 of 7 14% Select "Yes" if you have been in contact with Stephanie Hurd, KQ's Family and Community Engagement Coordinator.(Required) Yes No This application is for the Full Day Pre-K for 2, 3, and 4-year-olds only. Will your child turn 4 years of age by August 15, 2024?(Required)YesNoWill your child turn 3 years of age by August 15, 2024?(Required)YesNoWill your child turn 2 years of age by August 15, 2024?(Required)YesNoUh Oh! Your child is not eligible for the Early Childhood Academy this year.Would you like to notified when your child is eligible?(Required)YesNoChild's Name(Required) First Last Child's DOB(Required) MM slash DD slash YYYY Parent's Contact Information(Required) First Last Phone(Required)Email(Required) 1.) CHILD'S INFORMATIONProvide information about your child. Please check to ensure accuracy!Student's Name(Required) First MI Last Suffix (Jr., etc.) Date of Birth:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age:(Required)Please enter a number from 1 to 7.Gender:(Required) Male Female Other Prefer not to answer Race(s) & Ethnicity:(Required) Black or African American White Asian Native American Hispanic or Latino Prefer not to answer Are you enrolling a second child?(Required) Yes No Student's #2's Name:(Required) First MI Last Suffix (Jr., etc.) Student's #2's Date of Birth:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Student's #2's Age:(Required)Please enter a number from 4 to 19.Student's #2's Gender:(Required) Male Female Other Prefer not to answer Student's #2's Race(s) & Ethnicity:(Required) Black or African American White Asian Native American Hispanic or Latino Prefer not to answer Are you enrolling a third child?(Required) Yes No Student's #3's Name:(Required) First MI Last Suffix (Jr., etc.) Student's #3's Date of Birth:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Student's #3's Age:Please enter a number from 4 to 19.Student's #3's Race(s) & Ethnicity:(Required) Black or African American White Asian Native American Hispanic or Latino Prefer not to answer Student's #3's Gender:(Required) Male Female Other Prefer not to answer Home Address:(Required) 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(Required)Select length of time at this residence.Less that 3 months3 to 6 months6 to 12 months1-2 years3-5 yearsMore than 5 yearsAny Legal Alerts?(Required)Are there alerts KQ needs to be aware of for child's safety?YesNoIf yes, explain: 2.) Parent or Guardian InformationProvide information for the primary caregiver for this child.Guardian Name:(Required) First Last Phone #:(Required)Email:(Required) Relationship:(Required)Select relationship to child.Mother (biological or adopted)Father (biological or adopted)GrandparentStepmotherStepfatherAunt or UncleOtherIs this person completing the form?(Required) Yes No If no, who is? First Last Guardian Address(Required) 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 Contact InformationAuthorized Pick Up?(Required)Designate whether this person has permission to pick up.YesNoPrimary Contact?(Required)Is this the primary contact for dismissal & emergencies?YesNoLegal Guardian?(Required)Does this person have legal custody?YesNoOtherIf no, who is the child's Legal Guardian?(Required) First Last Parent Guardian Additional InformationPlease provide demographic information about the parent/guardian listed above. Relationship Status:(Required)Select current relationship status.SingleIn a relationshipMarriedDivorcedWidowedOtherEducation Level:(Required)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:(Required) Full-Time Part-Time Unemployed Not working Employer Name:(Required) Job Title or Position:(Required) Work Phone:(Required)Work Address (Optional)(Required) 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?(Required)Do you want to add information for another adult?YesNoParent/Guardian Information #2Optional: contact information for a second parent or guardian. Parent/Guardian Name:(Required) First Last Relationship:(Required)Select relationship to child.Father (biological or adopted)Mother (biological or adopted)GrandparentStepmotherStepfatherAunt or UncleOtherPhone Number:(Required)Email:(Required) Does this person live with child?(Required)Indicate if currently residing in same home as child.YesNoSometimesAddress(Required) 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?(Required)Designate whether this person has permission to pick up.YesNoEducation Level:(Required)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:(Required) Full-Time Part-Time Unemployed Not working 3.) Household InformationPlease provide accurate demographic information about the household. This information is for data purposes and will not be shared. Type of Residence(Required) Apartment House Other Rehousing or Homelessness in past 18 months?(Required) Yes No How many adults (anyone 18+) live in household with child?(Required)Please enter a number from 1 to 15.How many children (anyone under 18) live in household? Including this child.(Required)Please enter a number from 1 to 15.Members of Household(Required) 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?(Required)Please enter a number from 0 to 15.How many sisters live with child?(Required)Please enter a number from 0 to 15.Number of adults in home currently employed Full Time:(Required)Please enter a number from 0 to 15.Number of adults in home currently employed Part Time:(Required)Please enter a number from 0 to 15.Number of adults in home currently Not Working:(Required)Please enter a number from 0 to 15.Number of adults in home graduated high school?(Required)Please enter a number from 0 to 15.List all siblings. Add row for each new sibling.(Required)First NameLast NameBirthday (mm/dd/yyyy) Add RemoveAnnual Household Income:(Required)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?(Required) Yes No 4.) Student's 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.)(Required) Yes No If yes, list conditions/concerns. Add a new row for each. Add RemoveDoes participant have a regular Primary Physician or Pediatrician?(Required) Yes Yes, but I cannot provide contact information at this time No, there is no pediatrician or primary physician Name of Physician:(Required) Prefix Dr.Dr.Mr.Ms. First Last Physician Phone:(Required)Insurance Name:(Required) Policy #:(Required) Hospital Affiliation:(Required) Emergency Treatment Authorization(Required) 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. Child Relase FormList those Authorized for Pick Up (add row for each):(Required)First NameLast NamePhoneRelationship Add Remove 4.) Emergency 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):(Required)First NameLast NameRelationshipPhone Add RemoveAdd row for each5.) Consents & AuthorizationPlease read the statements below carefully. Acknowledgement of Consent(Required) I consent to the statement below.I give consent for the individuals I've indicated on this application under "Approved for Release" can sign my child in and out of KQ programming. I acknowledge Knowledge Quest will not be responsible for my child when they leave the program. I agree to not 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 the said release. 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.Media Release(Required) 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(Required) 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(Required) 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(Required) 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. Documentation requirements listed below(Required) I agree to provide the documents.The following documents will be required for the final step in the enrollment process: Parent's Photo Identification Parent's Proof of Income (3 most recent check stubs, 2021 W-2/Tax Return, Proof of Families First, SSI Disability or Child Support if Applicable) and proof of income for all adult members of the household 2 Documents for Parent's Proof of Address (MLGW Bill, Telephone Bill, Lease, or Mortgage in Parent's Name) Certified Copy of Child's Birth Certificate Certificate of Child's Immunization with Current Physical Exam (Within the past 12 months) Child's Health Insurance Card Child's Social Security Card Copy of IEP (If applicable) **Child must be present to be screened during the enrollment process If you have any questions, please call (901) 207-3694 6.) Knowledge Quest HistoryPlease provide details about the child and the child's family's previous experiences with KQ programming.Have sibling(s) ever been in KQ programming?(Required)Select whether sibling(s) participated past or presentYesNoSibling(s) newly registering nowIf yes, when?(Required)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)Who is your Family Coach?Efua ColemanJennifer CrenshawLatisha BlackburnPreet KaurLavada HermanRicco MitchellI have not been assigned a Family Coach yet.Fill out your Intake form to be assigned a Family Coach.https://s1k.4b6.myftpupload.com/programs/family-stability-initiative/register/ Thank you for being a Knowledge Quest Member! Δ