Nā Liko Enrollment Application

Nā Liko Enrollment Application
Student Info:
School Year*
School Day Classroom
School Day Group Assignment
Name*

First Name Last Name
Preferred Name
Age:*
Grade:*
Sex:*
Date of Birth:*
MM/DD/YY
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Info:
Mother's Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer:
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Father's Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer:
Home Phone Number:

Area Code Phone Number
Work Phone Number:

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
Individuals authorized to pick this student up from the afterschool program. Emergency contacts are contacted when the student is sick or injured and staff are unable to speak to a parent or guardian.
1. Name

First Name Last Name
Relationship to Child:
Phone Number:

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact

YesNo
2. Name

First Name Last Name
Relationship to Child:
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact:

YesNo
3. Name

First Name Last Name
Relationship to Child:
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact:

YesNo
4. Name

First Name Last Name
Relationship to Child:
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact:

YesNo
5. Name

First Name Last Name
Relationship to Child:
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact:

YesNo
To add additional authorized pick-up persons or emergency contacts, please email their information to us at NaLikoLLC@gmail.com and we will add them to your application.
Student Health Information:
Medical Conditions:
Allergies:
Medications Taken:
When are they taken:
Insurance Provider:*
Policy Number:*
*

I acknowledge that Nā Liko staff are not able to provide or administer medicines. In the event of an emergency, Nā Liko staff will follow the guidance of 911 operators, including administering life-saving tools the student carries.
My child has permission to watch PG movies:*

YesNo
Media Release:

I grant Nā Liko, LLC permission to use photographs, videos, artwork, writing, and other media made by or containing my child in all types of Nā Liko, LLC company media, including on the website, in brochures, and in powerpoint presentations.
*

I consent to the above media releaseI DO NOT consent to the above media release
Guest Speaker Media Release:

I grant guest speakers that visit Nā Liko, LLC afterschool program permission to use photographs and videos of my child on their social media accounts and websites for the purpose of sharing their experience at the Nā Liko, LLC afterschool program.
*

I consent to the above guest speaker media releaseI DO NOT consent to the above guest speaker media release and would like to be asked for permission each guest speaker activity
Any other comments (ex. likes, dislikes, triggers) thy may help us care for your child:

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Nā Liko Enrollment Application

Student Info:

Parent/Guardian Info:

Student Health Information:

Parent Registration Agreement