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*Please return all copies to our Main Office
2021-2022 St. Theresa After School Program
Hours: End of School
5:30 pm
Child Care Options & Rates
Please check applicable boxes & fill out blank spaces.
Registration Form
Questions? Call 808-306-1261 or 808-262-4538
1 Child:
2 Child:
Last Name First Name
*Daily rate (8 days or less only)
Last Name First Name
*Daily rate (8 days or less only)
Parents / Legal Guardians (AUTHORIZED TO PICK UP CHILD)
Parents Name Email Address HDL # Work Phone Cell Phone
Parents Name Email Address HDL # Work Phone Cell Phone
4 Mailing Address City State Zip
5 Medical Conditions/Allergies Child 1: Child 2:
6 Doctors Name Phone
State ZipDoctor Address City
Authorized Pick-Up & Emergency People (Other than parent / legal guardians):
7 Medical Insurance Policy #
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 1:15 ratio.
Name HDL # Work Cell
Name HDL # Work Cell
I hereby authorize Kama‘aina Kids and its employees to exercise these discipline policies in regard to my child.
Signature of Releasor Date
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, subse-quently 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 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 memb’s 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.
