Uluhāhāloa Afterschool Program Online Application
Please complete all questions on this form. After you submit we will contact you via email in a timely manner regarding next steps. Mahalo nui for your interest in this program!
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Child's First Name: *
Child's Last Name: *
Address:
City:
State/Zip Code: *
Gender:
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Date of Birth *
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DD
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YYYY
What school does your child attend? *
What current grade is your child in? *
Is your child of Native Hawaiian ancestry? *
Youth T-Shirt Size: *
Emergency Contact Information:
Please provide immediate emergency contact information below.
First and Last Name: *
Relationship to child: *
Primary Phone Number: *
Email *
This program will be held ever Wednesday afterschool. Will your child will be able to make it every Wednesday? *
Will your child have a way to and from the program? *If yes, please provide us with the  information of who is AUTHORIZED to drop-off/pick-up your child *
Please note: Loko Ea Fishpond is NOT responsible for transportation to and from afterschool program.
Name: *
Relationship to child: *
Contact Number *
Medical- any injuries, allergies, medical conditions that we should know about? If YES, please explain: *
This program will require various forms of participation (sun exposure, dust, sand, pollen, insects working with native species, getting dirty, etc.). Does child have any allergies, dietary restrictions, or other conditions that we should know about? *
Submission
Submitting this form to the best of your ability means you ALLOW your child to participate in this Uluhāhāloa Afterschool Program. Please sign your child  in and out of the fishpond each day of the program.
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