2024-2025 Saint Joseph- Hilo

Saint Joseph - Hilo

Hours: End of School - 5:30 PM
Questions? Call 808-960-2226 or 808-262-4538
Child 1*

C1 First NameC1 Last Name
Child 1: Gender*
Child 1: Date of Birth*

MonthDayYear
Date
Child 1: Grade*
Child 1: Program*

$200/Monthly
Child 1: Medical Condition(s)?*

YesNo
Child 1: Medical Condition Description*
Register another child?*

YesNo

Child 2*

C2 First NameC2 Last Name
Child 2: Gender*
Child 2: Date of Birth*

MonthDayYear
Date
Child 2: Grade*
Child 2: Program*

$200 Monthly
Child 2: Medical Condition(s)?*

YesNo
Child 2: Medical Condition Description*

PARENT OR LEGAL GUARDIANS AUTHORIZED TO PICK UP CHILD
Parent/Guardian 1*

P1 First NameLast Name
Parent/Guardian 1: Email Address*
example@example.com
Parent/Guardian 1: Drivers License#*
Parent/Guardian 1: Work Phone
Parent/ Guardian 1: Cell Phone*
Parent/Guardian 2

P2 First NameP2 Last Name
Email
example@example.com
Parent/Guardian 2: Drivers License #
Parent/Guardian 2: Work Phone
Parent/Guardian 2: Cell Phone
Mailing Address*

Mailing Address

Street Address Line 2

CityState

Zip

DOCTOR INFORMATION
Doctors Name*
Doctors Phone*
Doctor Address

Doctor Address

Street Address Line 2

CityState

Zip
Medical Insurance*
Policy #*

AUTHORIZED PICK-UP & EMERGENCY POINT OF CONTACT
POC 1: Name
POC1: Drivers License #
POC 1: Work Phone
Please enter a valid phone number.
POC 1: Cell Phone
Please enter a valid phone number.
POC 2: Name
POC 2: Drivers License #
POC 2: Work Phone
Please enter a valid phone number.
POC 2: Cell Phone
Please enter a valid phone number.
SPONSOR
I hereby agree that, if Kama‘aina Kids staff is unable to contact me or one of the persons listed as emergency contact, I hereby consent that if my child exhibits signs of illness or injur, that at the discretion of the Kama‘aina Kids supervisor on duty, my child may be taken to the nearest medical facility and be given any examination or treatment that is deemed necessary by the personnel of the medical facility and, if permissible by medical facility, subsequently released to Kama‘aina Kids Supervisor or staff-in-charge.

I hereby authorize Kama‘aina Kids to use my child’s name and video or photograph at any time and in any manner in connection with its advertising, publicity, and public relations programs. The video-photo may only be used by Kama‘aina Kids. No further claims will be made by me.

I hereby give my child permission to attend and participate in the activities conducted by Kama‘aina Kids’ program. These activities include aquatics, off-property excursions, van transportation, and enrichment activities.

DISCIPLINE
Discipline is used to assure the safety and well being of all program participants. All children are expected to respect themselves, other people and their property. If a child is not following the guidelines of Kama‘aina Kids staff consistent with these expectations, then the child will take a time out from the activity at the staff members discretion. A child with consistent behavior problems will be sent to Kama‘aina Kids’ Program Site Coordinator who may contact the parents for the purpose of removing the child from the program. Kama‘aina Kids reserves the right to refuse any child’s future participation in its programs.

I hereby authorize Kama‘aina Kids and its employees to exercise these discipline policies in regard to my child.

MISC.

$30.00 Return Check Fee ∙ $5.00 Late Pick-Up Fee ∙ $25.00 Late Payment Fee

Kama‘aina Kids is an equal opportunity organization and does not deny enrollment or discriminate on the grounds of race, color, religion, sex, or national origin. Eligibility to participate in this program is reliant upon verification of a child’s ability to function safely in a 1:9 ratio.
Print Name*
Signature of Releasor*

Clear
Date*

MonthDayYear
Date
Should be Empty:

PARENT OR LEGAL GUARDIANS AUTHORIZED TO PICK UP CHILD

DOCTOR INFORMATION

AUTHORIZED PICK-UP & EMERGENCY POINT OF CONTACT