KWLA, Inc. Academic Program Registration

KWLA, Inc. Academic Program 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
Name *

First Name Last Name
M.I.
Birth Date *

Month Day Year
Age *
Gender *
Ethnicity
Parent Email Address *
example@example.com
Current School Year *
Grade *
Have you previously applied to or attended KWLA? *

Yes No
If yes, what year? *
How did you hear about KWLA? *
Please select how you heard about KWLA
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
Current Residence Information
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/ Guardian Employment Information
Home Phone Number *
Please provide telephone number.
Parent Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Telephone *
Upload Parent Photo ID *

Parent Photo ID-Driver License
Cancel of

Cell Phone Number *
Please provide telephone number.
Emergency Contact 1
Name *

First Name Last Name
Phone Number *
Provide telephone number.
File Upload Photo ID *

Photo ID of Authorize Person to Drop off/pickup student
Cancel of
Emergency Contact 2
Name *

First Name Last Name
Phone Number *
Please provide telephone number
File Upload Photo ID *

Photo ID of Authorize Person to Drop off/Pickup student
Cancel of
Physician and Medical Information
Name *

First Name Last Name
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. *

School Information 1
School Name & Address
City *
State *
Select State.
Current Grade *
Teacher Name *
Teacher Email *
example@example.com
Current Grade *
Notes
Please inform KWLA staff of any other vital information you think we may need to know in the event of an emergency. Thank you. *
KWLA Afterschool/Summer Program 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 AFTER-SCHOOL PROGRAM 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 Signature *

Clear
Print Student Name *

First Name Last Name

Permission Granted by Parents/Guardian: *

Yes

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

KWLA PARENT AGREEMENT CONTRACT

1.     The KWLA Program is an equal opportunity employer. No person, based on race, sex, religion, color, or national origin, will be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program.

2.     KWLA exercises the right to pray over food and during all general activities. KWLA’s platform is based on character education a value systems that are consistent with Right Living spiritual values. If the parent/guardian opposes please put in writing that you want your child(ren) to be exempt from the above.

3.     The KWLA Program will abide by the state of Alabama Department of Human Services regulation and safety procedures.

4.     The KWLA Before Program will be open Monday – Friday from 6:00 am – 10:00 am and After School Program will be open from Monday - Thursday from 3:00 p.m. to 6:00 p.m. and Fridays from 3:00 p.m. – 5:00p.m. to provide quality before and after school care for children attending local schools in grades K5 – 8th. K-12 grades for students with a current IEP may attend KWLA Program.

5.     The KWLA Program will be closed when the local schools are closed. If school is cancelled due to weather while the children are in school, KWLA Program will be closed also. Parents will be notified of KWLA open dates on holidays. Additional fee will apply. (see handbook policy)

6. KWLA Program will provide a daily nutritious afternoon snack.

7.     While every attempt will be made to protect your child’s personal property, KWLA Program will not be responsible for any personal items brought to the program.

8.     Positive reinforcement is our primary method of maintaining discipline at KWLA. In cases where our discipline procedure of time‐out, isolation, counseling, parental contact, and behavior redirection are not effective; the child may be removed from the program by the director.

9. KWLA Program will not administer medication without first obtaining written consent on KWLA medication form from the parent/guardian. If the child’s temperature reaches 101 degrees, or the child appears to be ill, the parent will be called to immediately pick up the child.

10.     In the event of an emergency, KWLA Program has the permission of the parent/guardian to administer first aid and/or obtain emergency medical treatment, if necessary, for the child’s welfare.

11.     In order to meet the special academic needs of a child, KWLA will obtain the parent’s permission to coordinate efforts with the child's teachers, principals, and school counselor.

12.     It is understood by the parent/guardian that children in our care are subjected to be interviewed by Child Care Licensing, DHR Special Investigations and/or law enforcement for investigative purposes and/or for determining our compliance with state of Alabama Licensing Requirements.

The KWLA After School Program fees are as follows:

13. REGISTRATION: Registration fee is $30.00 for each household entering the program. The registration fee is non-‐refundable fee and due upon initial registration along with the first week of tuition. If your child is absent for two week without communicating with KWLA program director, your child's space is no longer available. Re-enrollment is required with registration fee.

14. The parent/guardian agrees to pay the weekly tuition fee as set by KWLA. All tuition fees are due one week in advance of services rendered. Checks are payable to KWLA. If for any reason, except illness with documentation from a physician, the account has not been paid by the close of business on Wednesday of that week, a late fee of $10.00 will be assessed. If the account has not been paid by the next Friday, the child will not be permitted to return until the past due account is brought current.

15. The parent/guardian agrees to pay $25.00 for returned or insufficient funds by their financial institution, counterfeit currency or CashAPP, or money order currency company. If payment is returned, KWLA Program reserves the right to require all future payments to be made in cash. All fees and penalties associated with collecting past due accounts will be the sole responsibility of the primary parent/guardian.

16. The parent/guardian agrees to pay a $1.00 per minute, per child for late pick-‐up fee starting at 6:01pm Mon – Thursday and 5:01 pm on Fridays and the time is determined by the clock at KWLA Program locations.

17. The parent/guardian agrees to notify KWLA Before and After School Program’s verbally to the director or by text message one week in advance of the removal of their child from the program. Parents/guardians will be responsible for the week’s tuition if advanced notification is not given.

18. This parent agreement is subject to change with a one week’s notice.
Parent/Guardian Signature *

Clear
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.

KWLA Registration

KWLA Registration Fee $45.00 registration fee per household. This is a one-time fee during registration.

$ 45.00 Quantity
Item subtotal: $ 0.00

KWLA Student Weekly Fee Due every Monday before close of business day

$ 85.00 Number of Students
Item subtotal: $ 0.00

Enter coupon

Total

$ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Name *

Child's Name Last Name
Parent/Guardian Signature *

Clear
Should be Empty: