Uluhāhāloa Afterschool Program Online Application
Mahalo for applying for the Uluhāhāloa Afterschool Program here at Loko ea.
Please be sure to click 'submit' after filling out this application.
*Application due for Session 1: January 10, 2020
*Application due for Session 2: March, 13, 2020
Which session are you applying for? *
First Name: *
Your answer
Last Name: *
Your answer
Address:
Your answer
City:
Your answer
State/Zip Code: *
Your answer
Gender:
Date of Birth
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DD
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YYYY
What school does your child attend? *
Your answer
What current grade is your child in?
Your answer
Native Hawaiian? *
Youth T-Shirt Size:
Emergency Contact Information:
Please provide immediate emergency contact information below.
First and Last Name: *
Your answer
Relationship to child: *
Primary Phone Number: *
Your answer
This program will be held ever Wednesday afterschool. My 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.
Your answer
Name: *
Your answer
Relationship to child: *
Contact Number *
Your answer
Medical- any injuries, allergies, medical conditions that we should know about? If YES, please explain: *
Your answer
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 dietary, or other conditions that we should know about? *
Your answer
Submission
Submitting this form to the best of your ability means you ALLOW your child to participate in this Uluhāhāloa Afterschool Program. Your child will need to be signed in and out of the fishpond.
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