KWLA, Inc. Registration

KWLA, Inc. Registration

Flowin' in the S.T.R.E.A.M
Knowledge Works Learning Academy/ Kai Wa'Diya Learning Academy, Inc.
Please have the following documents available to submit with your application.
- Current Copy of Individual Education Plan (IEP), if applicable
- Progress Report
- Report Card
- Immunization Form
- Proof of Residence( ex. bills, lease)
- Government-issued Identification (with picture)
- Insurance Card
* When registering more than one child in the same household, the above documents should be submitted for each child.
Student Information
STUDENT NAME *

First Name Last Name
M.I. *
Birth Date *

Month Day Year
Age *
Gender *
Ethnicity *
Current School Year *
Grade *
Have you previously applied to or attended KWLA? *

Yes No
If yes, what year? *

Does your child have an Individual Educational Plan-IEP? *

Yes No
File Upload Student IEP

Cancel of
Will your child need accommodation? *

Yes No Other
How did you hear about KWLA? *
Please select how you heard about KWLA

Parent/Guardian Name *

First Name Last Name Suffix
Current Residence Information
HOME ADDRESS *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/ Guardian Employment Information
WORK ADDRESS. Place N/A if parent/guardian is not working *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/ Guardian Email Address *
example@example.com
Home Phone Number *
Please provide telephone number.
Cell Phone Number *
Please provide telephone number.
Upload Parent Photo ID *

Parent Photo ID-Driver License
Cancel of

Emergency Contact 1 and Authorize Person to Pickup/Drop Off
Name *

First Name Last Name
Current Address of Authorize person *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Provide telephone number.
File Upload Photo ID *

Photo ID of Authorize Person to Drop off/pickup student
Cancel of
Relationship to the Child *
Please be specific

Emergency Contact 2 Authorize to Pickup/Dropoff Child
Name *

First Name Last Name
Current Address of Authorize Person *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please provide telephone number
Relationship to Child *
Please be specific
File Upload Photo ID *

Photo ID of Authorize Person to Drop off/Pickup student
Cancel of

Physician Name, Address and Phone. * Please provide
Physician Name *

First Name Last Name
Physician Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Physician Office Phone Number *
Please provide telephone number.
Preferred Hospital *
Insurance/Health Coverage (Company) *
File Upload Proof of Medical Insurance *

Cancel of
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns. *

KWLA Afterschool/Summer Care Behavior Contract

Please Read Before Signing

Upon signing this document, both the parent and student agree to the guidelines set forth and will abide by the discipline actions issued if this contract is not followed.

·         I will be on time and attend Peer Tutor of KWLA and/or KWLA Afterschool/Summer Program daily.

·         No cell phone usage allowed during Peer Tutor of KWLA Sessions and/ or KWLA Before and After school/Summer Program

·         During the time I can use the computers it will be for educational purposes only.

·         I will be respectful of my peers, fellow teachers, and all program staff. This means that I will speak to others in a respectful manner and tone of voice.

·         I will follow directions of Peer Tutor of KWLA and KWLA Before & Afterschool/Summer staff.

·         I will not threaten or cause physical harm towards others, including possessing sharp or other dangerous instruments.

·         I will respect the personal space of others and keep my body to myself.

·         I understand that disrespectful behavior includes, but is not limited to, hitting, punching, kicking, biting, spitting, swearing, lying, bullying, and refusing to listen to the KWLA staff.

·         I will be respectful of the building, and any other location I may visit while attending KWLA Before and After school/Summer Program

·         I will not litter, vandalize, steal, or destroy items that do not belong to me.

·         I will follow all van/bus rules while riding to KWLA Before and After school/Summer Program.

·         I agree to follow all KWLA Before and After- school/Summer Program rules including those that are not listed on this behavior agreement or rules set forth by KWLA Board of Directors.

KWLA Before and After-school/Summer Program utilizes the following if any of the above is broken:

First Occurrence – The first occurrence will result in a phone call home. A senior staff member will explain to the parent/guardian what happened and why such behavior is not acceptable. In the case where kicking, biting, or other severe behavior occurs, the child may automatically be given one day suspension from the program, with no refund for that day.

Second Occurrence – The second incident may result in immediate expulsion from KWLA Programs without refund.
Signature *

Clear
Date *

Month Day Year
Date

Knowledge Works Learning Academy, Inc- KWLA Permission to Publish/Photo Release Form

Occasionally Knowledge Works Learning Academy (KWLA) will produce photographs and short clips for video purposes to promote and advertise our nonprofit efforts in the community. Please indicate your willingness to allow your child/children’s image to be displayed on KWLA promotional materials, website, and/or documents. KWLA and its associates asserts:
- No children will be exploited through use of images
- Names of children will be kept private
- Addresses, Social Security numbers and other identifying markers will be kept private
- There is no financial gain from photos (such as stock photos files for sale)
I hereby grant KWLA permission to use my likeness in a photograph, video, or other digital media (“photo”) in their publications, including web-based publications, without payment or other consideration.

I understand and agree that all photos will become the property of KWLA and will not be returned.

I hereby irrevocably authorize KWLA to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge KWLA from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT:
Student Name *

First Name Last Name
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date

KWLA, Inc. WAIVER AND RELEASE FORM

I am a parent whose child (ren) is participating in the Knowledge Works Learning Academy (KWLA) programs. As a condition of my participation in this program, I agree to and understand the following:

1. Release, waive, discharge and agree not to sue the Trustees of the Knowledge Works Learning Academy and all its successors, assigns, affiliates, officers, directors, employees and agents ("KWLA") from all manner of actions and causes of action, suits, debts, accounts, judgments, claims and demands whatsoever in law or equity, and attorney's fees, including all claims arising out of any incidents involving personal injury in any way by reason of participation in the program.

2. Assume any and all risks arising from his/her participation in the voluntary activity named above, including without limitation, the risks of bodily injury or property damage, the unavailability of emergency medical care or the negligent or the deliberate act of another person.

3. Indemnify, defend and hold the Trustees of Knowledge Works Learning Academy, its directors, officers, employees and agents harmless from any and all claims, causes of action, dam ages, judgments, costs or expenses that arise out of or relate to the negligent or intentional act or omission of the undersigned. Each of the undersigned expressly acknowledges that he/she has read and understands this Agreement and Release and signs it freely and voluntarily.
Signature *

Clear
Date *

Month Day Year
Date

Knowledge Works Learning Academy, Inc (KWLA)

PARENT/GUARDIAN CONSENT FOR RELEASE/ EXCHANGE OF INFORMATION FORM

This consent for the release and exchange of information is for the purpose of sharing information on my child’s educational performance in the Phenix City/Russell County/Lee County -Smith Station School Systems and/or distance learning educational institutions and surrounding school districts, to include his or her academic achievement and social-emotional development. The purpose of releasing and exchanging this information shall be to assist individuals to plan and provide a high-quality year-round before/after school/summer educational program for my child. Individuals with whom Phenix City/Russell County/Lee County-Smith Station school and/or distance learning educational institutions and surrounding school districts personnel may share this information in accordance with this release are limited to those involved in the funding, planning, implementing, and evaluating of the Knowledge Works Learning Academy, Inc (KWLA).

I hereby authorize Phenix City/Russell County/Lee County Schools- (Smith Station) Schools and/or online educational institutions and surrounding school district personnel to release and exchange specified information concerning my child’s educational and behavioral performance with personnel associated with the above-named agencies. I understand that this information is to be used by personnel at these agencies in planning, delivering, and evaluating of educational, social-emotional, and recreational services to my child in the KWLA year-round programs being conducted by the above-named agencies. This information may include the following:

a)       Discussions with my child’s school teacher(s) and other staff (e.g., administrators, specialists, counselors), as well as review of surveys about my child completed by these school staff.

b)       Data on my child’s progress reports, report card grades, Individual Education Plans (IEPs), results of End-of-Grade and End-of-Course exams, and other group examinations.

c)       Information on findings of individualized psycho-educational evaluations, if any.

d)       Other information that may be found in my child’s records at school, including his or her

attendance at school and disciplinary incidents at school; and

e)       Observation of my child in school settings by staff associated with the above-named agencies.

The doctrine of informed consent has been explained to me. I understand the nature of the information to be released, the need for this information and use which will be made of this information, and that there are statutes and regulations requiring recipients of this information to maintain the confidentiality of the information and use it only for its intended purposes in the KWLA program. I hereby acknowledge that this consent is truly voluntary and understand the consent will begin on August 1, 2020, and expire automatically on May 31, 2098. I further acknowledge that I may revoke this consent at any time except to the extent that action based on this consent has been taken.

KWLA Release of Records and Exchange of Information Form Last Revised April 2021
Student Name   First Name*   Last Name*
DOB blank*
SSN or Student # *
Teacher Name   First Name*   Last Name*
School Name   *
Parent/ Guardian Name:    First Name*   Last Name*
Parent Gardian Signature *

Clear
Date *

Month Day Year
Date

Knowledge Works Learning Academy, Inc.

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. KWLA, INC., (“the program”) has put in place preventative measures to reduce the spread of COVID-19; however, KWLA, INC cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending KWLA could increase your risk and your child(ren)’s risk of contracting COVID-19.

_______________________________________________________

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending KWLA and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the program may result from the actions, omissions, or negligence of myself and others, including, but not limited to, KWLA employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at KWLA or participation in KWLA programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless KWLA, INC., its employees, agents, collaborative community partners and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the program, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any camp program.
Parent Signature *

Clear
Date *

Month Day Year
Date

Print Parent Name *

First Name Last Name
Student Name *

Clear
Print Student Name *

First Name Last Name

Permission Granted by Parents/Guardian: *

	Yes	No
Activities AWAY from KWLA
Transportation provided by KWLA, Inc. facility
Swimming/wading activities provided by KWLA, Inc facility:

Activities AWAY from the KWLA facility *

Clear
Date *

Month Day Year
Date
Transportation provided by KWLA, Inc facility Signature *

Clear
Date *

Month Day Year
Date
Swimming /wading activities provided by KWLA, Inc facility. Signature *

Clear
Date *

Month Day Year
Date

EMERGENCY AUTHORIZATION

(DHR-CDC-739)

I give permission for the KWLA facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency)
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date

AUTHORIZATION FOR ADMINISTERING MEDICATION/MEDICAL PROCEDURES (DHR-CDC-1949)

Dear Parent/Guardian,

Your written permission is required to administer medication or medical procedures to your child. Any prescription drug or over-the-counter drug sent to the KWLA facility must be in its original container and must be clearly labeled with your child's name, the name of the drug, and directions for administering the drug. A new authorization form is needed each week. If it is absolutely necessary for your child to be given medication while at the child care facility, please complete the following information. (If medication will not be administered type NA in the blanks to move on to the next part)

Child's Name   *

Prescription Number   *

Name of Medication   *

Amount of medication   *

Amount of medication to be given at each dosage

Instructions (how to give or apply, such as given by mouth, apply to skin, inhale, drops in eyes, etc.)   *

Time of the last dosage given at home   *

Time(s) of dosage(s) to be given at the child care facility   *

Please give my child the above-named medication at the time(s) and in the amount(s) indicated   Signature*
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date

I, First Name Last Name ) agree to all terms in the parent contract, policy, and procedures of KWLA, Inc. By signing, I agree to take full responsibility for all tuition fees for educational services I have requested for my child (ren). I also agree to provide KWLA with an online review of services my child received.
Parent/Guardian Signature *

Clear

My Products

KWLA Registration Fee $45.00 registration fee per household. This is a one-time fee during registration. ($2.77 convenience debit or credit charge is included in the fee)

$ 47.77 Quantity
Item subtotal: $ 0.00

KWLA After-School Weekly Student Fee Due every Monday before close of business on Wednesday ($2.77 convenient fee for debit/credit cards is included in this fee)

$ 87.77 Quantity
Item subtotal: $ 0.00

Enter coupon

Total

$ 0.00

Should be Empty:

KWLA, Inc. Registration

Household Information