First Day Packet

EMERGENCY CARD

This information needs to be completed every school year
School
Date *

Month Day Year
Students Name *

First Name Middle Initial Last Name
Grade *
Language Spoken at Home *
Sex: *

Male Female
Birthday *

Month Day Year
Home Address *
Apt. No.
City *
Zip Code *
Is Home Address same as Mailing Address? *

Yes No
Mailing Address *
Zip Code *
Child resides with *
Father's/Legal Guardian's Information:
Father's/Legal Guardian's Name:
Employer:
Father/Legal Guardian Active Duty:

Yes No
Branch of Military Service:
Home Number
Bus. Number
Cellular Phone
Father/Legal Guardian Email:
Mother's/Legal Guardian's Information:
Mother's/Legal Guardian's Name:
Employer:
Mother/Legal Guardian Active Duty:

Yes No
Branch of Military Service:
Home Number
Bus. Number
Cellular Number
Mother/Legal Guardian Email:
example@example.com
EMERGENCY CONTACTS: In case child listed above becomes ill or is injured at school and I cannot be contacted, the school authorities have my permission to contact and release my child to the custody of one of the following:
Emergency Contact
1) First & Last Name *
First & Last Name
1) Relationship *
Relationship
1) Phone Number *
Phone Number
2) First & Last Name *
First & Last Name
2) Relationship *
Relationship
2) Phone Number *
Phone Number
Family Physician *
Family Physician Phone Number *
Dentist *
Dentist Phone Number *
If my child needs to be taken to an emergency facility, he/she will be taken to the nearest one.

To assure prompt attention to your child,

PLEASE NOTIFY SCHOOL OF ANY CHANGE IN PHONE NUMBER OR ADDRESS.
Parent's/Legal Guardian's Signature *

Clear
INSURANCE INFORMATION:
My Child has health insurance: *

Yes No
If Yes, Check:

QUEST/Medicaid Private
If Private, check your plan:

HMSA Kaiser Tri Care
MEDICAL CONDITIONS:
Medical Conditions: *

My child does not have any medical conditions. My child has a medical condition(s)
Please check all that apply

Asthma Blood Disorders Bone/Joint Disorders Cancer/Leukemia Chronic Cough/Wheezing Diabetes Type 1 Diabetes Type 2 Genetic Condition Hearing Problems Heart Condition High Blood Pressure Metabolic Disorder Seizures Skin Problems Vision Problems Allergies
Allergies

Bee Sting Food Medications
For the above allergy(ies), reaction occurs by:

Skin contact By inhalation By ingestion
Date of last reaction:

Month Day Year
Date
Describe the allergic reaction that occurs:
MEDICATION(S) TAKEN:

Yes No
My child takes the following medication(s):
Reason for taking the medication(s)
OTHER HEALTH CONCERNS: *

Yes No
OTHER HEALTH CONCERNS: *
Do you have any other children? *

Yes No

Acceptable Use Guidelines
1. Users are responsible for their account(s). Users should make appropriate use of the system and network-provided protection features and take precautions against others obtaining access to their computer resources. Individual password security is the responsibility of each user.

2. Users are forbidden from using techniques designed to cause damage to, deny access by legitimate users of computers or network components connected to the Internet or result in the loss of the recipient's work.

3. Users shall not use another user's account or password without proper authorization.

4. Users are forbidden from circumventing security measures on school or remote computers and networks.

5. Users shall not download, install or run security programs or utilities which reveal weaknesses in the security of a system. For example, the users shall not run password cracking programs on any of the Department's computing systems.

6. Users are prohibited from sending unsolicited, commercial and/or offensive e-mail.

7. Users are prohibited from using any form of electronic media to harass, intimidate or otherwise annoy another person/group.

8. Users shall not make copies of system configuration files for their own unauthorized personal use or to provide to other people/users with unauthorized uses.

9. Users may post pages that are consistent with the public, non-profit educational mission of the Department of Education and are in compliance with all state and federal laws, including those prohibiting obscenity, defamation or copyright infringement.

10. Use of the Department of Education network resources to illegally distribute or duplicate unauthorized copyrighted or licensed material is prohibited.
11. Use of the Department of Education network to post, send, or retrieve pornographic material, inappropriate text or graphic files, or files dangerous to the integrity of the network are prohibited.

12. Use of the Department of Education network system in a manner that encumbers system and network resources to the point that usage causes interference with others' services is prohibited.

13. The Department of Education network and computing resources shall not be used for political lobbying.

14. The Department of Education is a non-commercial user of the web and use of the web must remain non-commercial. No personal money-making activity may be conducted through the use of the Department's computing and networking resources.

15. The Department of Education is not responsible or liable for materials in violation. Users are responsible for the content of their postings and obtaining all necessary permissions or licenses for any material used.

16. Users shall not make unauthorized copies of copyrighted software, except as permitted by law or by the owner of the copyright.

17. Sending or receiving unlawful information via electronic communications; using electronic communications illegally in ways that violate local, state, federal, or international laws or statutes are prohibited.

18. Users shall always cooperate with requests from the system administrators for information about the users' computing activities.

19. Users are requested to report any weaknesses in the Department of Education's computer security, any incidents of possible misuse or violation of this agreement to the proper authorities by contacting Network Support Services Branch via email: nssb@k12.hi.us.

20. The Department of Education reserves the right to investigate and monitor any accounts, servers, or machines suspected of policy violation.

21. The Department of Education reserves the right to disconnect any device that is the source of malicious or suspicious activities without notice until the machine in violation is cleaned or fixed.

22. The Department of Education reserves the right without notice to freeze and delete an account that is engaging in activities that violate the Department of Education's policy or the source of spamming, abusive or malicious activities.
I Student Name* , along with, Parents Name, agree to the terms and conditions of the acceptable use guidelines.
Student Name: *
First & Last Name
Grade *
Date: *

Month Day Year
Date
Student Signature: *

Clear
Parent/Guardian Name: *
First & Last Name
Date: *

Month Day Year
Date
Parent Signature: *

Clear

Emergency School Closing Procedure:
Student First & Last Name *
Kumu *
Grade *
Date *

Month Day Year
Date
Father/Legal Guardian *
Phone Number *
Mother/Legal Guardian *
Phone Number *
In the event that Ka ʻUmeke Kāʻeo closes before the end of the school day, I would like to have my child: *

Dismissed to walk home. Wait for me at school until I pick him/her up. Release my child to the following person(s) whom I have notified & will come for him/her. These people may be in addition to those listed on the emergency card.
1) Name: *
Phone Number *
2) Name: *
Phone Number *
Parents/Guardians Signature *

Clear

PARENT/GUARDIAN AUTHORIZATION
FOR STUDENT HUAKAʻI

School Year 20202-2021
Students Name *
First & Last Name
Kumu *
Grade *
My (our) child First & Last Name* in papa Grade* has my consent to attend and participate in all huakaʻi activities connected with his/her being a student at Ka ʻUmeke Kāʻeo (KʻUK) Public Charter School. My child has permission to travel by KʻUK bus, public carriers, chartered bus, KʻUK vans, private or commercial vehicles driven by an adult representative, or walk with adult supervision for all huakaʻi purposes.
I expressly waive and release any and all claims against the Department of Education of the State of Hawaiʻi, Ka ʻUmeke Kāʻeo Public Charter School and any duly appointed representatives on account of accident, injury or illness that may be incurred by my child while participating in any activity; including but not limited to travel and huakaʻi as referred herein.
You will be kept abreast of all huakaʻi schedules, waivers, and needed supplies through your child’s kumu and the KʻUK keʻena. Huakaʻi at KʻUK are a substantial part of our curriculum and participation by all students in all activities is important for learning. Your child will be required to participate in all huakaʻi activities unless otherwise specified through submitting in writing to your child’s kumu their name, activity, and date of non-participation.
In case of illness or injury to said child/student, we (I) hereby consent to and authorize such medical or dental treatment as deemed necessary, and agree to pay such medical and dental costs if incurred. We will make every effort to contact you before such action is taken.
Please specify any medical conditions or allergies your child suffers from in the space provided below:
Please specify any medical conditions or allergies your child suffers
Parent/Guardian *
Date *

Month Day Year
Date
Signature *

Clear
Mother/Legal Guardian: Name
First & Last Name
Phone Number
Father/Legal Guardian: Name
First & Last Name
Phone Number
1)Emergency Contact: First & Last Name
Relationship
Phone Number
2) Emergency Contact: First & Last Name
Relationship
Phone Number
My Child has health insurance: *

Yes No
Medical Insurance *

HMSA Kaiser
Family Physician: *
Family Physician Phone Number *

Should be Empty:

EMERGENCY CARD

Father's/Legal Guardian's Information:

Mother's/Legal Guardian's Information:

Emergency Contact

INSURANCE INFORMATION:

MEDICAL CONDITIONS:

Acceptable Use Guidelines

Emergency School Closing Procedure:

PARENT/GUARDIAN AUTHORIZATION

FOR STUDENT HUAKAʻI

Kaʻa ʻŌhua

Kaʻa ʻŌhua Registration Form

ʻOhana Information

Emergency Contact Other Than Parent/Guardian

MVA

Section 3:

Section 4: Contact Information

Emergency Contact Information

Section 5:

Section 6: Parent/Legal Guardian

Free & Reduced Price School Meals

EKF Acceptance of Conditions, Release of Indemnity Form

One Call

One Call

Other Keiki enrolled at Ka ʻUmeke

	First & Last Name	School	Grade
1)
2)
3)
4)

	Name	Age	School	Grade
1)
2)
3)