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Student Application KAILUA HIGH SCHOOL Mālama 21st Program

Summer 2022

Parent/Guardian Name*
This is the main email address we'll use for your household.
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?
Summer 2022
Student is entering this grade - Fall 2022
Registering For:
Student Name*
Date of Birth*
Please describe, or write "none"
Please describe, or write "none"
Who do we call first in an emergency? Name and phone number (text number if different)

Over 18 yrs Student May Sign. Under 18 yrs of age, PARENT /LEGAL GUARDIAN must sign.

Data Consent*
Liability, Media, Covid Policy - Consent*
Parent or Guardian Signature, please
Parent or Guardian whose signature appears above.