Aloha na kia`i aina Keiki Enrichment Program

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ONLINE REGISTRATION FORM BY KONOHIKI RESTORATION PROJECT

CHILD #1 NAME *

CHILD #1- BIRTH DATE *

YYYY

CHILD #2- NAME

CHILD #2- BIRTH DATE

YYYY

CHILD #3- NAME

CHILD #3- BIRTH DATE

YYYY

Address *

PARENT/ GUARDIAN #1- NAME *

PARENT/ GUARDIAN #1- PHONE *

PARENT/ GUARDIAN #1- EMAIL *

PARENT/ GUARDIAN #2- NAME

PARENT/ GUARDIAN #2- PHONE

PARENT GUARDIAN #2- EMAIL

NORTH SHORE CONTACT IN CASE OF EMERGENCY

*MUST LIVE NORTH OF HANALEI BRIDGE, WILL BE CONTACTED IN CASE OF EMERGENCY HANALEI BRIDGE CLOSURE*

NORTH SHORE CONTACT- NAME *

REALATION TO STUDENT *

N.S CONTACT PHONE *

ALTERNATE PHONE

PLEASE PROVIDE NAMES ALLOWED FOR PICKUP

*NON PARENTAL/GUARDIAN NAMES MUST BE ON LIST TO SIGN CHILD OUT*

PICK UP #1- NAME *

PICK UP #1- RELATION TO CHILD *

PICK UP #1- PHONE *

PICK UP #2- NAME

PICK UP #2- RELATION TO CHILD

PICK UP #2- PHONE

PICK UP #3- NAME

PICK UP #3- RELATION TO CHILD

PICK UP #3- PHONE

CHILD #1- PLEASE CHECK ALL THAT APPLY

HAWAIIAN DECENT

OLELO HAWAI`I

STRONG SWIMMER (8+ YEARS EXPERIENCE)

WA`A EXPERIENCE

LO`I EXPERIENCE

LIFT HEAVY OBJECTS UP TO 25 LBS

RUN ½ MILE IN 10 MINUTES OR LESS

CHILD #1- ONGOING MEDICAL CONDITIONS, ALLERGIES, OR TAKING MEDICATION? *

CHILD #1- INSURANCE INFORMATION: *

HMSA

ALOHA CARE

KAISER PERMANENTE

Other:

CHILD #1- POLICY NUMBER *

CHILD #2- PLEASE CHECK ALL THAT APPLY

HAWAIIAN DESCENT

OLELO HAWAI`I

STRONG SWIMMER (8+ YEARS EXPERIENCE)

WA`A EXPERIENCE

LO`I EXPERIENCE

LIFT HEAVY OBJECTS UP TO 25 LBS

RUN ½ MILE IN 10 MINUTES OR LESS

CHILD #2- ONGOING MEDICAL CONDITIONS, ALLERGIES, OR TAKING MEDICATION?

CHILD #2- INSURANCE INFORMATION:

HMSA

ALOHA CARE

KAISER PERMANENTE

Other:

Clear selection

CHILD #2- INSURANCE POLICY NUMBER

CHILD #3- PLEASE CHECK ALL THAT APPLY

HAWAIIAN DESCENT

OLELO HAWAI`I

STRONG SWIMMER (8+ YEARS EXPERIENCE)

WA`A EXPERIENCE

LO`I EXPERIENCE

LIFT HEAVY OBJECTS UP TO 25 LBS

RUN ½ MILE IN 10 MINUTES OR LESS

CHILD #3- ONGOING MEDICAL CONDITIONS, ALLERGIES, OR TAKING MEDICATION?

CHILD #3- INSURANCE INFORMATION:

HMSA

ALOHA CARE

KAISER PERMANENTE

Other:

Clear selection

CHILD #3- INSURANCE POLICY NUMBER

WOULD YOU LIKE TO VOLUNTEER YOUR SKILLS AND SERVICES TO OUR PROGRAM?

Yes

Other:

Clear selection

WOULD YOU LIKE US TO CONTACT YOU WHEN THERE ARE MEETINGS AND WORK DAYS?

Yes

Other:

Clear selection

PLEASE READ AND AGREE *

I GIVE PERMISSION TO THE ORGANIZATION TO SEEK MEDICAL SERVICES IN THE EVENT OF AN EMERGENCY USING THE INSURANCE POLICY ABOVE AND WILL BE RESPONSIBLE FOR ANY EXPENSES INCURRED.

I AGREE TO PROVIDE ITEMS ON SUPPLY LIST BEFORE MY CHILD CAN BEGIN. (PLEASE CONTACT US PRIVATELY IF HELP IS NEEDED WITH ITEMS)

MY CHILD MAY NOT INCUR MORE THAN 5 ABSENCES DURING THE PROGRAM. (PLEASE NOTIFY DIRECTORS AHEAD OF TIME FOR ANY KNOWN APPOINTMENTS)

MY CHILD WILL BE ON TIME, HAVE ALREADY EATEN BREAKFAST, AND GONE TO THE BATHROOM BEFORE CLASS STARTS. GIRLS WILL NEED TO WEAR THEIR HAIR UP.

I UNDERSTAND A PHOTOCOPY OF PARENT/LEGAL GUARDIAN I.D, ALONG WITH CHILDS BIRTH CERTIFICATE ARE REQUIRED TO COMPLETE REGISTRATION.

MY SON/DAUGHTER MAY RIDE IN A VEHICLE DRIVEN BY AN ADULT TO THE ACTIVITY.

I ACKNOWLEDGE THERE MAY BE PHOTOGRAPHS TAKEN OF THE ACTIVITIES AND PARTICIPANTS. I AGREE TO ALLOW ANY AND ALL PHOTOS TAKEN OF MY CHILD TO BE USED BY KONOHIKI RESTORATION PROJECT 501 (3)(C). FOR THEIR WEBSITE AND OTHER CULTURAL PROMOTIONAL MATERIAL, WITH NO COMPENSATION.

I UNDERSTAND MY CHILD MAY BE SUBJECT TO RANDOM TEMPERATURE AND HEAD LICE CHECKS. CHILDREN WITH TEMPERATURES OVER 99° F, AS WELL AS ANY LICE FINDINGS WILL BE SENT HOME.

I AGREE TO PARTICIPATE 3 HOURS PER MONTH WITH KONOHIKI RESTORATION PROJECT THROUGH VOLUNTEERING OR DONATIONS UP TO $20/HOUR.

Required

BY AGREEING, I HAVE SIGNED THE ABOVE TO THE BEST OF MY KNOWLEDGE AND I GIVE PERMISSIONS FOR MY CHILD AGE 18 YEARS OR YOUNGER TO PARTICIPATE IN OUTDOOR ACTIVITIES, INCLUDING WATER ACTIVITIES AND WILL NOT HOLD THE PARTIES INVOLVED ACCOUNTABLE FOR ANY ACCIDENTS THAT MAY OCCUR. *

YES, I AGREE

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