KELII Christmas Family Social Registration Form 2024

Keiki Educational Living Independent Institute Christmas Family Social

Sensory Friendly Event
Registration Information

If you are a volunteer or vendor with someone with autism or other special needs, please include all their information on this form.
Name*

First NameLast Name
I am.... (please check all that apply)

A Parent of an Autistic or Special Needs ParticipantA Caregiver (Parent, Relative, Agency or Friend)An Autistic or Special Needs ParticipantAn Event Volunteer (additional information will be sent via email from kellifoundationhi@gmail.com)A KELII Advisory/Board MemberKELII StaffA Member of Harbor Church West OahuAn Event Vendor (additional information will be sent via email from keliifoundationhi@gmail.comOther
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Name and age group of registrant. Click +Add Row to add additional registrants.*
Which Neurodivergent Group applies to you?
Select all that apply...

NoneAutism SpectrumADHDDown SyndromeLearning Difficulties (e.g. Dyslexia)Mental Health ConditionsSocial AnxietyDevelopmental DisabilitiesPhysical DisabilitiesNeurological Genetic DisordersNon-Verbal
Concerns

Due to safety and security reasons, are there any behavioral concerns we should know about?
Select all that apply...

Self InjureAggressiveElopesLight SensitivitySound Sensitivity
I am... (select all that apply)

Native HawaiianSamoanTonganOther PolynesianWhiteAsianAfricanHispanicParticipant is a Military DependantParticipantʻs guardian is an Active Military
PLEASE DONATE. We will contact you via email. Thank you for giving!

Drinks (Bottled Water, Juice)Brand new or gently used toys, stuffed animals, games, books etc.Snacks (pre-packaged, ready to serve items)Gift CardsFinancialNot at this time
Be A World Changer!
Select the option for additional information you want to be provided:

Prospective Partnership informationVolunteer OpportunitiesParent EventsKeiki Events
Waiver Form
WAIVER FORM

LIABILITY WAIVER:

In signing this release, I acknowledge that I understand the intent thereof, and I hereby agree and absolve and hold harmless Keiki Education Living Independent Institute (K.E.L.I.I.) corporate sponsors, cooperating organizations, and any other parties connected with this event in any way singly or collectively from and against any blame and liability for any injury, misadventure, harm, loss, inconvenience, or damage hereby suffered or sustained as a result of participation in the event or any activities associated therewith.

PHOTOGRAPHY/VIDEO WAIVER:

For valuable consideration received, I grant to the Keiki Education Living Independent Institute (K.E.L.I.I.), cofounders, coordinator, committee, representatives, and assigns the permission & irrevocable right to use and publish photographs, still and/or moving including videos, of me and/or my guest/s in which we may be included, for the restricted purposes of promotion, including advertising, in any manner and medium; and to alter and composite the same without restriction and without my inspection and/or approval.

I hereby release Keiki Education Living Independent Institute (K.E.L.I.I.) cofounders, coordinator, committee, representatives, and assigns from all claims and liability relating to said photographs or videos.

The bottom of this waiver form indicates you acknowledge that you have read, understand and agree with each waiver point. Furthermore, this form pertains to and includes all individuals registered by the responsible parent/guardian/caregiver. Failure to agree will result in an incomplete registration and will be denied participation in this event.
Please Choose One *

I AGREEI DECLINE
Should be Empty:

Keiki Educational Living Independent Institute Christmas Family Social

Registration Information

Which Neurodivergent Group applies to you?

Concerns

Be A World Changer!

Waiver Form