Papahana Kuaola Waiver Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Mahalo for your interest in participating in the educational programs and/or volunteer services offered at Papahana Kuaola (PK). This is a non-profit mālama ʻāina education organization. Our mission is to create quality programming focused on environmental restoration and economic sustainability fully integrated with Hawaiian knowledge. Papahana Kuaola provides educational activities for all ages. These activities are financially subsidized by numerous funding agencies, organizations, and corporations. One of our major funders is Kamehameha Schools (KS). KS and PK are committed to collecting data on every student learner in order to verify that we are doing our best to serve the people of Hawai'i. Both KS and PK assure you that the information you provide on this form will be kept in strict confidence. The data is used exclusively for internal PK reports to KS in order to maintain their support and to keep the cost for learning activities at a minimum. The information will not be used by PK for any reason except that state above.

Kindly complete this online form and submit it with an electronic signature and date. If you are a parent/legal guardian, please fill out the form with your participating minor's information (under 18 years old).

Date of Visit *

YYYY

School/Organization *

Group ID Number *

Age Category *

0-2 years old

3-4 years old

Kindergarten - Grade 3

Grade 4 - Grade 5

Grade 6 - Grade 8

Grade 9 - 12

Post-high (enrolled in college/university)

Adults/Parents (not enrolled in college/university)

Educators

KS: K-12 Campus-based activities

First Name *

Middle Name *

Last Name *

Date of Birth *

YYYY

Zip Code *

Gender *

Male

Female

Ethnicity *

Please identify the participant's ethnicity by selecting one or more of the following:

Hawaiian

African American

Asian

Caucasian

Hispanic or Latino

Other Pacific Islander

Other

Required

Emergency Contacts

List the participant's primary and secondary emergency contact. Please include the contacts' name, their relationship to the participant, and cell/preferred phone number.

Medical Information

Please provide the following medical information: Hospital/Clinic preference, physician's name and phone number, insurance company and policy number, allergies/special health considerations, and medication(s) taken regularly.

Media Consent

I, the undersigned, give permission for Papahana Kuaola and approved parties to use media including photographs, video recordings, and audio recordings taken of myself and/or my child (if under 18 years old) on learning/service activities in its non-profit work. By typing my name below, I am affixing my signature to this document and agreeing to all terms stated above.

Authorization *

I, the undersigned, give permission for myself and/or my child to participate in the activities offered at Papahana Kuaola. I understand and acknowledge that doing so involves inherent risks of injury for myself and/or my child. I release the landowner(s), and Papahana Kuaola, its staff, and Board of Directors from liability in case of an accident during activities, as long as normal safety procedures have been followed. I authorize all medical and surgical treatment as may be performed or prescribed by the attending physician and/or paramedics. I waive my rights to informed consent of treatment for the participant only in the event that Emergency Contacts (above) cannot be reached in the case of an emergency. Typing my name below indicates that I have read, understand, and agree to all terms stated above.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Papahana Kuaola. Report Abuse

Forms