Lavaroots Kohala Dance Tuesdays Registration Form

FALL SEMESTER 2026

AFTER- SCHOOL JEDI: HIP HOP/ CREATIVE EXPRESSION at Kohala Intergenerational Center at Kamehameha Park
Student Information

Personal & Health & Contact
Name

First NameLast Name
Birth Date

MonthDayYear
Age (at time of classes)
Grade
T-shirt Size:
List Any Allergies or things we should be aware of:
Any Medical needs?
Parent / Guardian Information

(All parent communications will be sent to this person)
Name

First NameLast Name
Name

First NameLast Name
Email
example@example.com
Email
example@example.com
Mom Cell Phone if applicable

Area CodePhone Number
Dad Cell Phone if applicable

Area CodePhone Number
If not a parent, what is relationship? if applicable
Emergency Contacts and Authorized Pick Up Persons
Emergency Contacts and Authorized Pick Up Persons
In case of emergency and unavaliability of parent, do we have your permission to go to hospital if needed?
THIS PROGRAM IS FREE!! Sponsored by Anonymous Angel Donor! If we decide to get tshirts there will be a $20 fee.

For Now JUST ENROLL AND HAVE YOUR KEIKI ATTEND! If you have questions/concerns please contact Lavaroots Director/Teacher Michál Anna Carrillo at: 808 987-4243 and save this number in case needed during the semester. Mahalo.
Date

MonthDayYear
Date
Signature
Should be Empty:

FALL SEMESTER 2026