Liko

Student Name

Student's Gender

Male
Female
Other

Student's Date of Birth

Any known food or medication allergies

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Phone Number

Address

Emergency Contact Name

Emergency Contact Phone

Release*

I hereby release, hold harmless, and indemnify Maui Hui Malama, its Board of Directors, employees and staff, from and against all claims, including but not limited to claims for property damage and/or personal injuries arising out of my child’s participation in MHM’s group, activities, or the rendering of any medical treatment. I understand that MHM will make reasonable attempts to notify me or the emergency contact as soon as possible in the event of illness or injury to my child to obtain authorization to administer necessary medical treatment. I further give consent to MHM to secure and authorize such medical treatment if MHM is unable to speak with me or the emergency contact for the above named child while under this supervision. I also agree to pay all costs and fees contingent upon receiving emergency medical care or treatment as secured or authorized under this content.

Media Release

I hereby give permission for Maui Hui Malama to use my or my child’s photo in but not limited to promotional materials including brochures, video, website, press release, TV, or radio ads.

Release of information*

I hereby release Department of Education and any school or educational entity to release educational information that pertains to my child or me. I also authorize Department of Education and or any other institution to release any other pertinent information including transcript records to Maui Hui Malama and to communicate by telephone, paper, or electronic format.

By checking here I agree to receive emails, mail, and phone calls on information regarding this program as well as other information related to Department of Education, any school, and any educational entity and Maui Hui Malama

Legal Guardian*

I confirm I am the legal guardian of the participant listed above or 18 years or older

Electronic Equipment Agreement

I understand that any electronic equipment that has been provided as a loaner is done so for the purpose listed in my child's personal plan. Should there be any damage to the equipment I take responsibility of the cost to replace the equipment. I understand that he equipment must be returned upon completion of the personal plan needs unless otherwise agreed upon in writing with Maui Hui Malama

Terms

I, the undersigned, agree to the terms above.

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