Kailua High Fall 2022

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cayen number

Student Name*

First Last

Nickname (if any)

My email address*

Date of Birth*

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My age as of today*

If you're over 18, you may sign permissions slips for yourself. If you are under 18, we'll email the parent you designate, to sign the permission as your legal guardian.

18+ years old

under 18 years old

Allergies*

Please describe, or write "none"

Medications*

Please describe, or write "none"

Grade*

Student is entering this grade - Fall 2022

9

10

11

12

Parent/Guardian Name*

First Last

Parent Guardian Email*

This is the main email address we'll use for your household.

Primary Phone Number*

The best number to reach someone in your household. Either the primary parent mobile phone, or a house phone.

Is there a second parent/guardian?

First Last

Second Parent/Guardian's Email

Hidden

Fall 2022

1

Emergency Contact 1*

Who do we call first in an emergency? Name and phone number (text number if different)

Emergency Contact 2*

Data Consent*

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 in Mālama / Lokahi 21st.

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 in Mālama 21st / Lokahi 21st 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. Questions? Please contact Derek Esibill (Program Director) wired@thepaf.org or Anna Ah Sam (Lead Evaluator) aahsam@me.com.

I consent to the release of my student information and program records as listed above.

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

In consideration of the services of the Mālama 21st / Lokahi 21st Programs, The Pacific American Foundation (PAF) 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 "Mālama 21st / Lokahi 21st"), I hereby AGREE AND CONSENT TO WAIVE AND RELEASE, to relinquish, and to forever discharge Mālama 21st / Lokahi 21st and its representatives 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:

I expressly agree to accept and assume all risk and liability, including personal injury, property damage, or death, arising during participation in Mālama 21st / Lokahi 21st program activities. Participation is purely voluntary, and I voluntarily elect to have my child/children participate in the activities. Whether on line or in person, I agree that my child/children/I will follow the instructions and direction of Mālama 21st personnel at all times. I agree that Mālama 21st / Lokahi 21st 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 Mālama 21st / Lokahi 21st 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 Mālama 21st / Lokahi 21st and all other persons or entities acting in any capacity on its behalf from any and all claims, demands, or causes of action, brought against me or Mālama 21st / Lokahi 21st, 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 Mālama 21st / Lokahi 21stt or it agents or representatives, 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 MMālama 21st / Lokahi 21st full authority to take whatever action it considers to be warranted in the case of a medical emergency, and I fully release Mālama 21st / Lokahi 21st from any liability for such decision or actions as may be taken in connection therewith. I authorize Mālama 21st / Lokahi 21st 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.
Should Mālama 21st / Lokahi 21st or anyone acting on its behalf be required to incur attorney's fees and costs to enforce this agreement, I agree to release, hold them harmless, and indemnify them for all such fees and costs.
Mālama 21st / Lokahi 21st reserves the right to make cancellations, substitutions or changes in case of emergency or changed conditions or in the interest of each group. If performance of the activities must be altered because of COVID-19, weather, strikes, government restrictions or regulations, act of god, or any other like reason, Mālama 21st shall have the right to make such alteration or cancellation of part or all of the activities as Mālama 21st / Lokahi 21st, in its sole discretion, deems necessary.
If I should ever file a lawsuit against Mālama 21st / Lokahi 21st, its representatives or agents, I agree to do so only in the State of Hawaii. I agree that the substantive law of the State of Hawaii shall apply regardless of any conflict of law rules that might provide otherwise. 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.

Photo and Media Permission: The Pacific American Foundation hereby has 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 PROTOCOLS and POLICY
I understand that participation is totally voluntary and Mālama 21st / Lokahi 21st is not responsible or accountable in the unlikely event my child/children contract COVID-19 due to participation activities hosted by the Mālama 21st / Lokahi 21st. I understand and agree that if I do not feel well, or test positively for covid, I should not attend face to face activities to help protect other students and their vulnerable ohana.

I have been provided the Mālama 21st / Lokahi 21st COVID Protocol Document (available online at thepaf.org/covid)

I agree and consent to the terms and conditions set forth above. I release and discharge Mālama 21st / Lokahi 21st, its representatives or agents, and all others acting on their behalf, on behalf of myself, my children, my heirs, assigns, personal representative, and the my estate for the right of being permitted by Mālama 21st to participate in the Activities and to use Mālama 21st / Lokahi 21st equipment and facilities.

I release, hold harmless, and agree to defend and indemnify Mālama 21st / Lokahi 21st, its representatives, agents, directors, officers, volunteers, advisors, and all other persons or entities acting on their behalf from any and all claims brought by, or on behalf myself, and which are in any way connected with such use or participation by me in the Activities.

I consent

Signature*

I am 18 years or older, and signing for myself as an adult.

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