Participant's Name*
First
MI
Last
Optional: Jr., etc.
Name*
First
Last
Date of Birth:* Gender:* Race(s) & Ethnicity:* Home Address:*
Guardian Name:*
First
Last
Is this person completing the form?* If no, who is?
First
Last
Guardian Address*
Same as child
If no, who is the child's Legal Guardian?*
First
Last
Employment Status:* Work Address (Optional)
Parent/Guardian Name:*
First
Last
Address*
Same as child
Employment Status:* Does student receive additional Educational Programs & Services through school?* School Information Consent* I have read and agree to the School Information Consent statement below.
By checking this box, I give permission for Knowledge Quest to access and/or obtain my child's education records, information, or data to fulfill state reporting requirements. This includes information from the school indicated above, Memphis-Shelby County School district, or through Seeding Success.
Type of Residence* Rehousing or Homelessness in past 18 months?* Members of Household* Select the family members who currently live with this child.
List all siblings. Add row for each new sibling.* Have utilities been disconnected in the past 18 months?* 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:*
Prefix
Dr. Dr. Mr. Ms.
First
Last
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 child's mode of transportation?* 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):* Additional Emergency Contact(s):* Add row for each
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.
Thank you for being a Knowledge Quest member!