In Person KPL After School Program Application

Student Information

Please provide all the information for student.
Welcome to the Kids on the Move for Success – Knowledge is Powerful in Literacy After School Program!

We’re excited to welcome you and your child(ren) to our in-person after school program focused on literacy, STEM, and financial literacy. This application helps us gather the necessary information to place your child(ren) in the appropriate group and ensure they have a meaningful and engaging experience.Once you complete this form and submit the required documents, our team will review your application and notify you of your child(ren)’s acceptance. We are offering free enrollment for the first 10 students accepted into the program for the 2025–2026 school year. After the initial spots are filled, all additional applicants will be placed on a waiting list and notified as openings become available.
Child Name

First NameLast Name
Date of Birth

MonthDayYear
Gender
School Currently Attending
School Student ID#
What grade is your child currently in for this school year?
County of Residence
Do you have any other child(ren) that you would like to enroll into one of our programs?
Did anyone refer you to this program? If so, what is there full name?
Ethnicity
Parent/Guardian Information

Please provide all the information for parents/guardians.
Father/Guardian Name

First NameLast Name
Work/Cell Phone

Area CodePhone Number
Email
example@example.com
Mother/Guardian Name

First NameLast Name
Work/Cell Phone

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
If parents cannot be reached, list nearby persons who will assume responsibility of your child(ren).

First NameLast Name
Please list all members of your household (name, gender, age and relationship to applicant.
Please select which applies to your child for their medical history.
Does your son/daughter have any other known allergies or adverse reactions to medications?
Does your child(ren) take any none prescribed mediation routinely? Please list:
Does your son/daughter have any physical disabilities or limitations?
Please share any additional information you would like us to know to support your child(ren) academic goals and social/emotional wellness needs
Does your child(ren) take any none prescribed mediation routinely? Please list:
Medical Release and Authorization. Be it hereby known that I do hereby give, consent, and forever grant to Kids on the Move for Success ("Assignee"), its representatives, licensees, marketers, and any other related parties or publishers of its promotional materials and their successors and assigns, the right to use, publish and copyright my picture, portrait or likeness, in photo, video and film format, in whole or part, including alterations, modifications, derivations, and composite thereof, in CDs, films, advertising and similar such promotions and renditions throughout the world. This right shall include the right to combine my likeness with others and to alter my likeness by digital or other means.

I further release all rights that I, or my heirs might have now and/or in the future to all or part of the said production, including but not limited to the publishing, printing, development, editing, and use in newspapers and other forms of printed media, social media, broadcasting, cablecasting, webcasting, podcasting, video on demand, or any other public or private presentation or screening purposes by developed or designed by the Assignee or its successors and assigns.

I also hereby release the Assignee and such other parties from any obligation to make any payment hereunder or from any other liability incurred in connection with the use of any of the materials described above. I knowingly and willingly waive any and all rights or entitlements, including payments for my appearance or for the subsequent distribution of the products related to this program.

Releaser hereby acknowledges his/her full and complete satisfaction with the terms of this Release.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature
Should be Empty:

Student Information

Welcome to the Kids on the Move for Success – Knowledge is Powerful in Literacy After School Program!

Parent/Guardian Information