Participant Name:*
First
Middle Initial
Last
Suffix (Jr., etc.)
Which program will you be particpating in? (Select all that all)* 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
Will s/he be primary contact? If no, who is the child's Legal Guardian?*
First
Last
Employment Status:* Work Address (Optional)
Address*
Same as child
Employment Status:* Does student receive additional Educational Programs & Services through school?* 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 participant'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.
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 media 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.
Feedback Consent I agree to the feedback policy.
I consent to having my child provide feedback regarding their experience at the Extended Learning Academy for improvement and reporting purposes.
Statement of Consent for Activities* I agree to the Consent for Activities statement below.
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.
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.
