SECTION I: DATA COLLECTION for Evaluation

All student data will be kept confidential, and no personal identifying information will be included with the program results. The following data collected by PAF from the School will be used only to assess the effectiveness of our 21st CLC programs. All data analyses and reports, both internal and to the Department of Education, will be stripped of any identifying student information.

1. First and Last Name
2. Date of Birth
3. School Attending
4. Teacher/homeroom teacher
5. Grade Level
6. 10-digit Hawai`i Dept. of Education Student ID
7. Gender
8. Ethnicity codes/description
9. Limited English Proficiency(ELL status)/English Learner Proficiency (EL status)
10. Special Needs or Disability (SPED status)
11. Free/Reduced Lunch status
12. Attendance records (excused/unexcused absences, tardiness)
13. Final Grades
14. Report Card Grades:1st, 2nd, 3rd, 4th quarter grades; % when applicable
15. Hawai`i Standardized State Assessment scores
16. Smarter Balanced Assessment scores

Surveys: We request that you and your participating child/children provide information in response to surveys we distribute twice per year ( parent and student surveys, pre and post) which ask questions about your child/children’s social-emotional skills, interests in careers and academic subjects, engagement in school and out-of-school activities, familiarity with community and culture, and how they feel about their experiences with Mālama 21 CCLC.

Benefits and Risks: Your feedback helps positively influence the program structure and design, and may benefit society if the results lead to a better understanding of how to design a place-based science program for middle and high school students with strong academic and personal outcomes. Whether or not your child chooses to participate in this study will not impact his or her relationship to the School as a student. The risks of participation are minimal.

Confidentiality and Privacy: All data will be kept confidential, in a secure location, and stored in a password-protected electronic file system. All data will be destroyed upon completion of the program and will be kept confidential to the extent allowed by law. No personal information will be included with the results.
Voluntary Participation: Participation is completely voluntary, and you and your child/children can choose freely whether to participate. At any point during the program, you or your child/children may withdraw permission with no penalty or loss of benefits to which they would otherwise be entitled.
I consent to the release of my child’s/children’s student information and program records as listed above, for each student listed above.

SECTION II: Assumption of Risk, Release, & Indemnity Agreement

In consideration of the services provided by The Pacific American Foundation and all of the related entities, partners, agents, directors, advisors, officers, employees, representatives, volunteers, and all other persons acting on behalf of the entities listed above (collectively, hereinafter "PAF"), I hereby AGREE AND CONSENT TO WAIVE AND RELEASE, to relinquish, and to forever discharge PAF on behalf of myself, my children, my parents, my heirs, assigns, personal representatives and estate from any and all claims, any and all causes of action that I (we) have or may have, whether past, present or future, whether known or unknown, whether anticipated or unanticipated, as follows in this document.

I expressly agree to accept and assume all risk and liability, including personal injury, property damage, or death, arising during participation in program activities. I understand that I voluntarily elect to have my child/children participate in the activities.

I understand that my child/children/I will follow the instructions and direction of PAF personnel at all times. I agree that PAF shall have the right to enforce appropriate standards of conduct, and that it may at any time terminate my/our participation in the Activities for failure to maintain these standards or for any actions or conduct which PAF considers to be incompatible with the interest, harmony, comfort and welfare of the Activities and the other students.

I voluntarily release, forever discharge, and agree to hold harmless and indemnify PAF from any and all claims, demands, or causes of action, brought against me or PAF, which are in any way connected with my/my child/my childrens' participation in the Activities or my use of equipment or facilities, including without limitation any claims alleging negligent acts or omissions of PAF, any injury or loss whatsoever suffered by me during the periods of independent travel (which I understand are unsupervised), any financial or other obligations or liabilities that I may personally incur during the course of the Activities, any intentional or unintentional damage or injury to persons or property caused in whole or in part by me, and any injury or loss that I/we myself may suffer.

I hereby grant to PAF full authority to take whatever action it considers to be warranted in the case of a medical emergency, and I fully release PAF from any liability for such decision or actions as may be taken in connection therewith. I authorize PAF to place me/my child/my children, at my own expense, in a hospital for medical services and treatment if necessary in an emergency. I also certify that I have adequate medical and other insurance to cover any injury or damage I/we may cause or suffer while participating in the activities. Alternatively, I agree to bear the full costs of such injury or damage myself.


I certify that I/we have no medical or physical conditions that could interfere with my safety or the safety of other in the Activities, or else I am willing to assume and bear the costs of all risks that may be created, directly or indirectly, by any such condition.


PAF reserves the right to make cancellations, substitutions or changes in case of emergency or changed conditions. PAF may cancel part or all of the activities, which in its sole discretion, it deems necessary.

I understand that any litigation I might file in relation to my/my child's participation shall only be filed in a court in the State of Hawaii, and that the laws of Hawaii shall apply, even if any conflict of law rules might provide alternate venues. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. I agree to indemnify PAF against all fees and costs which may be incurred in connection to my child's or my participation in any way.

Photo and Media Permission: I grant PAF permission to photograph, film or otherwise record and use images of myself and/or my child/childrens' name, voice, and/or likeness, bibliographical identification, and/or work for educational purposes and for publicizing and promoting the Program and its activities.

COVID-19 Protocols for all children If my child exhibits any symptoms of COVID, I agree they will NOT attend any in-person activities.
Parent(s) or Guardian of minor children
I agree and consent to the terms and conditions set forth above. I release and discharge PAF its representatives or agents, and all others acting on their behalf, on behalf of myself, my children, my heirs, assigns, personal representative, and the Minor's estate for the right of the Minor being permitted by PAF to participate in the Activities and use equipment and facilities.

I release, hold harmless, and agree to defend and indemnify PF from any and all claims brought by, or on behalf of the Minor, and which are in any way connected with such use or participation by the Minor in the Activities.