Hui MalamaYouthServicesAfter-School Program 2007

1980 Main Street, Wailuku and

Hawaiian Canoe Club, Kahului

(808) 242-9730

REGISTRATION FORM

Student’s Last Name: First Name:

Male Female Age: Birthdate: School:

Street Address:

City: State: Zip Code:

Home Phone: Cell Phone:

Mother’s Name:

Best Daytime Contact Number: Best Evening Contact Number:

Father’s Name:

Best Daytime Contact Number: Best Evening Contact Number:

In Case of Emergency Notify:

Emergency Contact Phone #: Relationship:

Last School Attended:

Does the student have any physical limitations, illnesses, conditions, behavioral issues that staff should be aware of? Please Describe:

See Back Page…

Please initial each statement as applicable:

____I give permission for my child to enroll in Hui Malama’s Youth Center Program

____I give permission for my child to attend Youth Services excursions. I understand that when excursions occur, all Sites will be closed for the duration of the excursions. (Parents will be notified of field trip plans in advance.)

____I understand that the Youth Services Program hours are Mondays-Fridays, 2:00pm to

5:00pm. The Main Street Youth Center, located at 1980 Main Street, will be open during these times except during certain holidays and designated excursions. I understand that I am responsible for arranging transportation for my child’s pick up from all youth services programs no later than 5pm.

____I give permission for HuiMalamaLearningCenter to use my child’s image in

promotional material, videos, brochures and newspaper articles.

____I understand that space is limited and I will be notified if my child is accepted into

the after-school program.

____I waive, release and hold harmless Hui Malama Learning Center, Hui Malama Youth Center, Hawaiian Canoe Club, other sponsoring agencies and their officers, employees or agents from any and all expenses, claims, losses or damages on account of injury arising out of participation in or transportation to programs, activities or events.

____ Our Youth Service Programs are designed to provide a safe, creative place for Maui’s youth. Youth are expected to act respectfully at all times and to follow rules and procedures. The following behaviors are prohibited:

  • Use of drugs, tobacco, alcohol or weapons
  • Violence, destruction of property
  • Yelling, profanity, gang symbols/affiliations
  • Use of my space or other sites that contain sexual or otherwise inappropriate content.

____While at the YouthCenter, students are expected to participate in scheduled classes & activities.

Please check if you are interested in any of the following for your child:

Homework Help Tutoring Vocational programs Oli

Paddling Video Production Music Classes Hawaiian Language

Parent or Guardian’s SignatureDate

Student’s SignatureDate