2026 - 2027 Bright Idea Afterschool (Club) Program

Child's Name

First NameLast Name

Child's Date of Birth (MM/DD/YYYY)

Date

Start Date 2026 - 2027 Bright Idea Afterschool (Club) Program starts Tuesday, September 1st, 2026.

Date

Child Gender

Child/Youth Race/Ethnicity (please select only one)

What language(s) does the child feel comfortable communicating in? (Select all the apply)

Child's Grade

Child's Miami Dade County Public Schools ID #

All students attending public or charter schools must have a schdool ID# entered

Child's School Name

Child's Homes Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Caregiver Name

First NameLast Name

Caregiver Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about the Knowledge Builders 2026 - 2027 Bright Idea Afterschool (Club) Program?

Caregiver Email Address

example@example.com

Caregiver preferred language for contact from The Children's Trust (please select only one)

Please note that The Children’s Trust may contact you via postal mail, email and/or text to ask about your satisfaction with services, and to make you aware of other Trust-funded programs, initiatives and events that may interest you.

As part of my child’s voluntary participation in this program, I give my permission for the information collected through this program to be submitted to The Children's Trust for program evaluation and quality purposes. The Children’s Trust provides funding for the program to operate and follows strict data privacy protections for the information collected (for example, following the Family Educational Rights and Privacy Act/FERPA guidelines).

Date Signed

Date

We want to get to know your child better so that we can provide the best possible experience in our programs. The questions on the next page address your child's need for assistance, any conditions or challenges, their communication methods, and the support they receive. This information is used to ensure that children and youth of all abilities are welcomed and supported in programs funded by The Children’s Trust.

To support your child/youth’s successful participation in this program, in what areas might they need extra assistance?

If you noted any areas of extra assistance needed, please be sure to speak individually with the program staff about your child’s needs and how the program can meet them.

What conditions doesyour child/youth have that are expected to last for a year or more? (mark all that apply)

Do any of the conditions noted make it harder for your child/youth to do things that others of the same age can do?

What are the mainways in which your child communicates? (mark allthat apply)

What, if any, helpdoes your child/youth receive at this time? (mark all that apply)

If you are interested in other community services or resources, you can call the 211 Miami Helpline, visit 211miami.org, or learn more about The Children’s Trust programs at www.thechildrenstrust.org. For special needs resources for individuals with disabilities and their families, visit www.advocacynetwork.org/services/individual-family-support or www.thechildrenstrust.org/cwd.

Additional Emergency Contact(s) (Optional)

The parent/guardian listed on the first page is considered the primary contact and is authorized to pick up their child unless otherwise notified. As students may be dismissed through authorized pickup or self-sign-out, please provide at least one additional emergency contact below. Individuals authorized for pickup will be granted access to Knowledge Builders' childcare management system, Procare, which is used to manage authorized pickups, emergency contacts, and program communications. Emergency contacts may be contacted in the event of illness, injury, an emergency, or if a student's dismissal plans change.

Additional Parent or Guardian Name (Optional)

First NameLast Name

Please add Additional Parent or Guardian as (Choose all that apply):

Additional Parent or Guardian Cellular Number (Optional)

Please enter a valid phone number.Format: (000) 000-0000.

Additional Parent or Guardian Email (Optional)

example@example.com

Additional Parent or Guardian Relationship to child (Optional)

I authorize this Additional Parent or Guardian to be added on the account. They will have full access to my child's ProCare account information and the ability to make modifications to the account (Optional).

ACKNOWLEDGEMENTS

By signing below, I, as the parent or legal guardian, acknowledge that G-rated and PG-rated movies, as well as other age-appropriate educational or family-friendly media that may not have an official rating, may occasionally be shown as part of the program. Knowledge Builders of Florida, Inc. will make reasonable efforts to ensure that all content is appropriate for the age and maturity level of participating students. By signing below, I authorize my child to view such content.

In the event of a medical emergency, I as the the Parent or Legal Guardian hereby authorize Knowledge Builders to seek emergency medical treatment for my child.

WAIVER AND MEDICAL RELEASE AGREEMENT: I as the the Parent or Legal Guardian hereby release Knowledge Builders of Florida, Inc., their employees, successors, agents, attorneys, and all other persons, corporations, or insurance companies liable or who might be claimed to liable, from any claims, demands, injured, or damages, resulting from any accident which may occur as a result of my child in the program

I acknowledge that I have received access to the 2026-2027 Parent Student Handbook. I understand that it is my responsibility to read and review the handbook and become familiar with all program policies, procedures, expectations, and dismissal protocols. I further acknowledge that the handbook contains information regarding the program's disciplinary practices, as required by Section 65C-22.006(3)(c)2., F.A.C., and that my signature below verifies receipt and review of this information.

I as the Parent or Legal Guardian hereby authorize and give consent to the staff of The Children’s Trust of Miami-Dade County and Knowledge Builders of Florida, Inc. consent and authorize to take/use still photographs, digital photographs, motion pictures, television transmission, and/or videotaped recordings (hereinafter “Recordings”) of me, my children, or my wards for educational, research, documentary, and public relations purposes. Any such recordings may reveal your identity through the image itself without any compensation to you, your child or wards. Any and all recordings taken of you, your child or wards shall be the sole property of The Children’s Trust and Knowledge Builders of Florida, Inc. with regard to the use of any recordings taken of you, your children or wards, you hereby waive any and all present and future claims you may have against The Children’s Trust of Miami-Dade County, their staff, service providers, employees, agents, affiliates, Board members and Knowledge Builders of Florida, Inc.

I as the Parent or Legal Guardian acknowledged receipt of Client Confidentiality Policy which states: Staff will to the best of their ability; ensure confidentiality and privacy in regard to history, records, and discussions about the people we serve. The very fact that an individual is served by Knowledge Builders of Florida, Inc. must be kept private and confidential; disclosure can be made only under specified conditions, which are described more in detail outlined in the 2026-2027 Parent Student Handbook. This means that staff shall not disclose any information about a person, including the fact that the person is or is not served by our organization, to anyone outside of this organization unless authorized by the client or the client's designee. The principle of confidentiality must be maintained in all programs, departments, functions, and activities. The following policy directives are mandatory. The full Client Confidentiality Policy can be reviewed in the 2026-2027 Parent Student Handbook.

I have read and fully understand the contents of this application. I have completed the application to the best of my knowledge and ability. I understand that if any information listed in this application changes, I will notify Knowledge Builders immediately. The child listed above has my permission to participate in the activities, trips, and events sponsored by Knowledge Builders. In case of an emergency, an Emergency Contact will be called if the Child's primary caregiver cannot be reached by phone. The undersigned, individually and as the Child's primary caregiver or guardian of the participant, hereby authorize Knowledge Builders of Florida, Inc. to carry out any measures deemed necessary should an emergency occur, including at the expense of the undersigned, appropriate medical treatment for the participant, and hereby releases Knowledge Builders, its employees, and agents, from any liability or claims arising out of the participant's engagement in the above described. Your signature below indicates that the information on this enrollment form is completed and accurate. You give permission for this information to be submitted to The Children's Trust for program quality and evaluation purposes. The Children's Trust provides funding for the program.

Student Self Sign-In/Sign-Out Authorization

This section authorizes the student to independently sign in upon arrival and sign out upon departure from the Life, Camera, Action Middle School Video Production Afterschool (Club) Program without a parent/guardian present. Without a parent/guardian signature below, the student may not self-sign in or self-sign out. In that case, a parent/guardian or another authorized adult age 18 or older must sign the student in and out each day.

Parental Authorization for Minor to Self-Sign-In: I, the undersigned parent or legal guardian, hereby authorize my child, a minor, to sign themselves into the Life, Camera, Action Middle School Video Production Afterschool (Club) program operated by Knowledge Builders of Florida, Inc. I understand that the standard procedure requires a parent/guardian or another authorized adult (18 years of age or older) to sign a child into the program each day. By granting this authorization, I permit my child to independently complete the sign-in process and enter the program without an accompanying adult. I acknowledge and agree that my child is responsible for arriving at the designated program location and properly signing in each day. I further understand that Knowledge Builders of Florida, Inc. is not responsible for the supervision of my child until they have arrived at the designated location, successfully signed in, and entered the program under staff supervision. By signing below, I accept full responsibility for my child's independent arrival and self-sign-in and release Knowledge Builders of Florida, Inc., its employees, agents, and representatives from any liability arising from my child's travel to the program or failure to properly sign in. This authorization shall remain in effect for the duration of the 2026-2027 school year, beginning Tuesday, September 1st, 2026, and ending Thursday, May 20th, 2027, unless revoked in writing by the parent or legal guardian.

Parental Authorization for Minor to Self-Sign-Out: I, the undersigned parent or legal guardian, hereby authorize my child, a minor, to sign themselves out of the Life, Camera, Action Middle School Video Production Afterschool (Club) Program operated by Knowledge Builders of Florida, Inc. I understand that the standard procedure requires a parent/guardian or another authorized adult (18 years of age or older) to sign a child out of the program each day. By granting this authorization, I permit my child to independently complete the sign-out process and leave the program without an accompanying adult. I acknowledge and agree that my child is responsible for properly signing themselves out before leaving the designated program location. I further understand that once my child has signed out and departed the program, they are no longer under the supervision of Knowledge Builders of Florida, Inc. or its staff. By signing below, I accept full responsibility for my child's departure from the program and any transportation, travel, or activities occurring after they have signed out and left the designated program location. I release and hold harmless Knowledge Builders of Florida, Inc., its employees, agents, and representatives from any liability arising from my child's departure from the program, travel from the program site, or failure to properly sign out. This authorization shall remain in effect for the duration of the 2026-2027 school year, beginning Tuesday, September 1st, 2026, and ending Thursday, May 20th, 2027, unless revoked in writing by the parent or legal guardian.

PARTICIPANTS BONUS

Participants of the 2026 - 2027 Bright Idea Afterschool (Club) Program received a participant bonus of $10 per day for attendance. Payments will only be made through Zelle at this time.

Who owns the Zelle account?

Other

If this Zelle account is linked to a phone number or email address, please provide that information?

What name is attached to the Zelle list above?