Kūpuna Program Waiver & Registration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Aloha!

Mahalo for your interest in registering for the KEY Project's Nā Pua o Ko'olau Kūpuna Program! Our Program is FREE and accepting applications for kūpuna who are: 50 years and older and lives in the regions of Kāne'ohe to Kahuku.

If you meet our two requirements, please complete all fields below.

Questions? Please email kupuna@keyproject.org or call 808-380-2359.

Mahalo!

Keilee and Mark

PERSONAL INFORMATION

First Name *

Last Name *

Birthday *

YYYY

Gender *

Female

Male

Want to subscribe to our weekly newsletter? Allows you to sign up for events and stay updated! *

Yes

Home Phone *

Cell Phone *

Home Address Street *

Home Address City *

Home Address Zip Code *

Mailing Address (if different)

IN CASE OF EMERGENCY INFORMATION

Please provide us with contacts that we can use to better assist you.

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number(s) *

Physician Name *

Physician Phone *

Medical Conditions/Allergies

Clear form

Never submit passwords through Google Forms.

This form was created inside of Kualoa-Heeia Ecumenical Youth (KEY) Project. Report Abuse

Forms