Youth Registration Form

Participant Information

Information about the child you're signing up.
Child's name

First NameMiddle NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Birthday

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Child's Age
FemaleMaleNon-BinaryPrefer not to sayOther
Child's Grade
Aliiolani ElementaryĀnuenue SchoolKa‘iulani ElementaryKalihi Kai ElementaryKalihi Waena ElementaryKapalama ElementaryKauluwela ElementaryLanakila ElementaryLikelike ElementaryMaemae ElementaryManoa ElementaryNu‘uanu ElementaryPauoa ElementaryPu‘uhale ElementarySalt Lake ElementaryWaimalu ElementaryHalau KumanaKulia AcademyDole Middle SchoolKalakaua Middle SchoolKawananakoa MiddleKe‘elikolani Middle (Central)Niu Valley Middle SchoolStevenson Middle SchoolWashington Middle SchoolDamien Memorial SchoolFarrington High SchoolMcKinley High SchoolRoosevelt High SchoolHomeschoolOther
Primary Contact Person
(ie. Mother, Father, Auntie etc)
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email Address
example@example.com
YesNo
If yes, please provide information, and list any medications being taken.
Physician Name or Healthcare Provider

First NameLast Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Insurance Carrier
Policy #
Emergency Contact Information
Emergency Contact Person's Name

First NameLast Name
Relationship to the participant?
ie. grandma, uncle etc.
Primary Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Information
Mother/Legal Guardian Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Legal Guardian Email
example@example.com
Mother/Legal Guardian Employer
If not employed, just put "none"
Father/Legal Guardian Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father/Legal Guardian Email
example@example.com
Father/Legal Guardian Employer
If not employed, just put "none"
Optional Information

Palama Settlement is a member of the Aloha United Way. The following information is voluntary and allows us to provide AUW with accurate information.
Number of family members in your household?
Mayor WrightKaahumanuKPTKamehamehaKukui GardensKauluwela IKauluwela IIIKalihi ValleyPuahalaOther
African AmericanAmerican IndianCaucasianChineseFilipinoHawaiianHispanicJapaneseKoreanMicronesianPart HawaiianSamoanVietnameseLaotianOther Pacific IslanderOther
Below 21,960Below 27,450Below 40,626Below 43,920Above 43,920
FlyerFriendWebsiteFacebook/Twitter/InstagramEmailOther
Liability Waiver
I, First Name Last Name , the adult applicant, parent and/or legal guardian of First Name Last Name hereby acknowledge and understand that I may have certain legal rights against PALAMA SETTLEMENT, their predecessors, successor and assigns, in the event of an accident and/or injury to my child/self or damage to property by PALAMA SETTLEMENT. NOW, THEREFORE, for good and valuable consideration, including but not limited to services provided to my child and/or me, I do hereby voluntarily and with full knowledge of my rights, completely and forever waive, release, acquit, and forever discharge PALAMA SETTLEMENT, its officers, directors, employees, agents and all other persons acting on their behalf (registered approved volunteers) (collectively “Released Parties”), jointly or severally, their successors and assigns, whether herein named or referred to or not, of and from any and all, and all matter of, actions and causes of action, rights, suits, demands, covenants, contracts, agreements, judgments, claims and demands, attorneys’ fees and costs or and damages of whatever name or nature whatsoever in law or equity, which heretofore have been, and which hereafter may be sustained.Further, I agree to defend, indemnify and hold harmless Released Parties from any and all claims, actions, causes of action, suits, expenses, damages of any nature and liabilities, including but not limited to attorneys’ fees and costs, arising out of or relating in any way to the services provided to my child or me by PALAMA SETTLEMENT and/or my or my child’s participation in any class, event or other activity provided or sponsored by PALAMA SETTLEMENT.
Signature

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Liability Waiver Signed?
Media Release Form
I, First Name Last Name , hereby grant permission to Palama Settlement, a Hawaii non-profit corporation (“Grantee”), to use and permit the use of, for any purpose, my name, image, in video, still, or other format, and the likeness and sound of my voice as recorded on audio, video or other forms of media (collectively, the “Materials”), across any and all formats and without payment or any other consideration to me. I fully and voluntarily understand that the Materials may be edited, copied, exhibited, published, or distributed, at the discretion of Grantee, and waive the right to inspect the Materials prior to Grantee’s use thereof. Additionally, I waive any right to royalties or other compensation arising or related to the use of the Materials. I also understand and acknowledge that the Materials may be used in diverse commercial, charitable, educational, and other settings within an unrestricted time period and geographic area.

The Materials may be used for ANY USE OR PURPOSE which may include but is not limited to: (i) presentations; (ii) courses; (iii) online/internet videos; (iv) advertisements/promotions; (v) news releases; (vi) oral histories; and (vii) archives.

I hereby release Grantee, all of Grantee’s representatives, employees, managers, members, officers, directors, parent companies, subsidiaries, sponsors, and agents, from all claims and demands arising out of or in connection with any use or exploitation of the Materials, including, without limitation, all claims for invasion of privacy, infringement of my right of publicity, defamation and any other personal and/or property rights.

The validity of this Media Release Form shall not expire and there is no geographic limitation on where the Materials may be distributed.

In case any one or more of the provisions contained in this Media Release Form shall become invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions contained herein shall not in any way be affected or impaired thereby and shall remain in full force and effect.

By signing this Media Release Form, I acknowledge that I have completely read and fully understand all of the provisions herein and completely and voluntarily agree to be bound by all of such provisions.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Signature

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If this release is obtained from a presenter under the age of 18, then the signature of that presenter’s parent or legal guardian is also required below.

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Media Release Signed?
Additional Forms

For Summer Enrichment Program
2026 SEP Pick-up Authorization

Please list three (3) people who are authorized to pick-up your child/children. All children must be signed out every day by one of the authorized persons listed below.
LATE PICK-UP

Please be prompt when picking up your child/children. After 3:00 p.m. (or 5:00 p.m. for those in extended day program) there will be a service fee of $5.00 for every 15 minutes (or fraction thereof), per child unless your child is in the extended day program. All fees must be paid the following day, (Monday if the late pick-up occurs on a Friday) or your child/children will be sent home from the program until the fee is paid.
Child's Name*

First NameLast Name
Name of Authorized Person #1*

First NameLast Name
Relationship to Child*
ie. mom, grandma, uncle etc.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name of Authorized Person #2

First NameLast Name
Relationship to Child
ie. mom, grandma, uncle etc.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Authorized Person #3

First NameLast Name
Relationship to Child
ie. mom, grandma, uncle etc.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please notify our staff if you have any concerns about unauthorized persons that may try and pick up your child/children. Please immediately report any legal orders (i.e. TROs) that are in force to our staff.
Your Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
Upload the Signed Pickup Authorization Here:

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Walk Home Permission Form

Summer Enrichment Program
Participant Name

First NameLast Name
Permission Statement:
I, the undersigned, hereby grant permission for my child, First Name Last Name, to walk home independently following the conclusion of the Summer Enrichment Program. I understand and acknowledge that Palama Settlement and its staff shall not be held responsible for the safety, well-being, or conduct of my child once they have departed the program premises.

I affirm that my child is both familiar with the route and equipped with the necessary knowledge of safety precautions to walk home independently. Furthermore, I accept full responsibility for ensuring that my child is aware of and adheres to all safety guidelines relevant to walking home alone.

In the event of an emergency, or should my child be unable to walk home for any reason, I will promptly notify the program staff.
Signature of Parent/Guardian

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Date

MonthDayYear
Date
Additional Notes/Instructions (if applicable):
Upload the Signed Walk Home Permission Slip Here!

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Walk Home Permission Slip Signed?
T-shirt Order Form

Summer Enrichment Program
Children are only required to wear their t-shirt on excursion days.
One t-shirt is included in the cost of enrollment.
Participant Name*

First NameLast Name
T-shirt Size*
ie. Youth Small, Youth Medium, Youth Large, Youth Extra Large, Adult Small, Adult Medium, Adult Large etc.
Yes I would like an additional t-shirt to purchase at $10.00.No thank you.

Thank you so much!

Please click submit below.
YesNo
Email to sign up for newsletter
example@example.com
Home Address (for audit and receipt purposes only)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Youth Registration Form

Choose Programs Below

For more info about Swim Lessons or Water Polo Contact:

Participant Information

Emergency Contact Information

Parent/Guardian Information

Optional Information

Liability Waiver

Media Release Form

Additional Forms

2026 SEP Pick-up Authorization

LATE PICK-UP

Please notify our staff if you have any concerns about unauthorized persons that may try and pick up your child/children. Please immediately report any legal orders (i.e. TROs) that are in force to our staff.

Walk Home Permission Form

T-shirt Order Form

Children are only required to wear their t-shirt on excursion days.

One t-shirt is included in the cost of enrollment.

Thank you so much!