Family Learning Vacation 2017 Registration
Aloha! Thank you for your interest in attending FLV 2017. Please fill out this form in its entirety, then mail payment to HSDB.
Family Last Name
Your answer
Mailing Address
Your answer
Phone Number
Your answer
Email
Your answer
Adult Guardian Name #1
Your answer
Relationship to child
Your answer
Cell Phone
Your answer
T-shirt Size
Adult Guardian Name #2
Your answer
Relationship to child
Your answer
Cell Phone
Your answer
T-shirt Size
Deaf/Hard of Hearing Child's Name
Your answer
Deaf/Hard of Hearing Child's Name Age
Your answer
Deaf/Hard of Hearing Child's Name T-shirt Size
List names, ages, shirt sizes for all other children
Your answer
Do(es) child(ren) have additional disabilities? If so, name child(ren) and describe:
Your answer
What mode(s) of communication does your deaf or hard of hearing child use? Please describe:
Your answer
Is anyone in the family a vegetarian or have a food allergy? Please describe.
Your answer
If you are from a neighbor island, please list names, DOB, and Hawaiian Miles numbers of all who are planning to attend.
Your answer
FEE SCHEDULE
The fee for the program is based on a scale for total family annual income. The fee will cover meals, childcare, children's program, adults program, and, if needed, neighbor island airfare. The fees paid by the families cover only a fraction of the program cost. Please pay according to what your family can afford. Send check to HSDB, Attn: Roz Kia, 3440 Leahi Avenue, Honolulu, HI 96815

Family Income: Total Fee for the Family
$40,000 - or more $200.00
$30,000 - 39,000 $150.00
$20,000 - 29,000 $100.00
Less than 29,000 $50.00

Limited number of scholarships are available.
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