*Please return all copies to our Main Office
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-
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.
Name HDL # Work Cell
Authorized Pick-Up & Emergency People (Other than parent / legal guardians):
$30 Return Check Fee
∙ $5 Late Pick-Up Fee ∙
$15 Late Payment Fee
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 1:20 ratio.
Name HDL # Work Cell
Doctor Address City
6 Doctors Name Phone
State Zip
5 Medical Conditions/Allergies Child 1: Child 2:
4 Mailing Address City State Zip
Parents Name Email Address HDL # Work Phone Cell Phone
Parents Name Email Address HDL # Work Phone Cell Phone
Parents / Legal Guardians (AUTHORIZED TO PICK UP CHILD)
Last Name First Name
*Daily rate (8 days or less only)
Last Name First Name
*Daily rate (8 days or less only)
2 Child:
2021-2022 Mary, Star of the Sea 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 808-445-5482 or 808-262-4538
1 Child:
2021-2022 Automatic Tuition Payments (ATP) Authorization Form
We are excited to offer the safety, convenience and ease of Tuition Express® – a
payment processing system that allows secure, on-time tuition and fee payments to
be made from either your bank account or credit card.
Payments will be processed beginning with the first business day of each month.
An email address is required to access receipts online.
Credit union members: please contact your credit union to verify account and routing numbers for automatic payments.
Payee Info
Payer Last Name
Payer First Name
Email Address
Child Last Name
Child First Name
Monthly Tuition
Morning Care
After Care
$ $ $
$ $ $
$ $ $
ATP Start Month
School Name
Total Monthly Tuition
Payment Option A (Credit Card)
American Express
Cardholder Name
Credit Card Number
Exp. Date
Billing Address
Payment Option B (Bank Account)
Bank or Credit Union Name
Bank or Credit Union Address
Routing Transit Number (see sample below)
Account Number (see sample below)
Please note that in addition to the monthly tuition charge, the following fees shall be assessed:
There shall be a $20 one-time processing fee assessed per family for each school year.
There shall be a $30 service charge assessed for any returned checks.
I hereby authorize Kama`āina Kids to initiate credit card charges to the above-referenced credit card account (Payment Option A) OR,
initiate debit entries to my checking or savings account, indicated above (Payment Option B). I am required to give 10 days written
notice to cancel this authorization.
Kama`āina Kids is a not-for-profit organization. Should you wish to make a tax-
deductible donation to assist our financial aid and scholarship program, please indicate
your donation frequency and amount here:
Print Name
Authorized Signature
Mary, Star of the Sea