ASAS HAWAII - 24-25 SY REGISTRATION FORM

ACKNOWLEDGEMENT OF STUDENT PICK-UP

Sign and Acknowledge Below
I UNDERSTAND THAT CONTINUED LATE PICK-UPS WILL RESULT IN MY CHILD’S TERMINATION OF ENROLLMENT FROM THE SUMMER PROGRAM. IF YOUR CHILD IS NOT PICKED UP WITHIN 30 MINUTES OF THE END OF PROGRAM, LAW ENFORCEMENT AUTHORITIES MAY BE CONTACTED.
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Signature

Clear
01 - Pick-Up Signature Date*

MonthDayYear
Date

BEHAVIOR AND ATTENDANCE POLICIES FOR PROGRAM

Initial and Acknowledge Below
AS AN ORGANIZATION DEDICATED TO MENTORING AND MOLDING THE CHARACTER OF YOUNG PEOPLE, WE PLACE ASPECIAL EMPHASIS ON SELF-RESPECT AND RESPECTING OTHERS. WE BELIEVE IT IS OF THE UTMOST IMPORTANCE THAT YOU AS PARENTS/GUARDIANS ARE AWARE OF THE DISCIPLINE POLICIES AND PROCEDURES THAT HELP MAINTAIN A CULTURE OF RESPECT AND INTEGRITY AT OUR PROGRAMS. YOU MAY OBTAIN A COPY OF THE ASAS STUDENT BEHAVIOR POLICIES FROM OUR WEBSITE (WWW.ASASHAWAII.ORG/BEHAVIOR).
I understand and support ASAS procedures as they pertain to student behavior, safety and conduct
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Initial

Clear
I understand that attendance at ASAS programs is voluntary
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Initial

Clear
I understand that it is my child’s responsibility to attend program
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Initial

Clear

PARENT LIABILITY/PARENT AUTHORIZATION

Sign and Acknowledge Below
Student's Full Name

First NameLast Name
In consideration of my minor/ward being allowed to participate in the After-School All-Stars (ASAS) Program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:

1. The above participant is in good physical and mental health and has never been declared medically ineligible for athletic competition. I further certify that the above mentioned participant has had no pre-existing medical condition or injury, listed as, but not limited to: exercise-induced asthma, cardiac or pulmonary (lung) disease, abnormal organ deficiencies, and head or neck injuries which may limit playing abilities; and,

2. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis, and death, and while particular skills, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist; and,

3. FOR MYSELF, SPOUSE AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERS, AND ASSUME FULL RESPONSIBLITY FOR MY CHILD’S PARTICIPATION; and,

4. I willingly agree to comply with the program’s stated and customary terms and conditions for my child’s participation. If however, I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will
remove my child from participation and bring such to the attention of the nearest official immediately; and,

5. I, for myself and of behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMIFY AND HOLD HARMLESS ASAS, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners, and leasers of premises used for the activity (“RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABLITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Signature

Clear
02 - Liability Signature Date*

MonthDayYear
Date

CONSENT FOR TREATMENT

Sign and Acknowledge Below
I understand that in case of emergencies, ASAS will make every effort to contact the parent(s)/guardian(s) before any treatment is given. In the event that we cannot be contacted, I hereby authorize the physician or hospital selected by ASAS to hospitalize, secure treatment for and to order injection, anesthesia, or surgery for my child. It is further understood that I (the parent/guardian) will assume full responsibility for any such treatment, including the payment of all costs and transportation and will hold ASAS, ASAS staff and volunteers, harmless there from.
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Signature

Clear
03 - Treatment Signature Date*

MonthDayYear
Date

PARENTAL CONSENT TO ACCESS REPORT CARDS AND OTHER SCHOOL DATA

Sign and Acknowledge Below
I authorize the release of the following school information regarding my child to ASAS: (a) student identification number, (b) school attendance, (c) demographic data, including, but not limited to the participant’s race/ethnicity, whether the participant receives special education services, whether the participant is considered an English Language Learner and whether participant participates in the free or reduced priced lunch program, (d) achievement data, including but not limited to, grades and standardized test scores, and (e) behavior data. Additionally, I understand that the information as noted above will only be shared with qualified professional staff from ASAS and with contracted third-party ASAS evaluators.
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Signature

Clear
04 - School Data Signature Date*

MonthDayYear
Date

PARENTAL CONSENT FOR PHOTOGRAPHS

Sign and Acknowledge Below
I hereby grant full permission to ASAS to use my child’s photograph in videotapes, publications, motion pictures, recordings and all other events to be used solely for the purposes of ASAS promotional material and publications, and waive any rights of compensation or ownership thereto.
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Signature

Clear
06 - Photo Signature Date*

MonthDayYear
Date

CONCUSSION MANAGEMENT ACKNOWLEDGEMENT

Sign and Acknowledge Below
I understand that it is my responsibility to review and complete the Brain Space Training Course resources provided by the Hawaii Concussion Awareness Management Program (HCAMP) and recommended by ASAS. I agree to support ASAS in holding strict standards with regard to concussion management as per the standards established in the Hawaii Concussion Law Act 262. (See Page 5 for additional details)
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Signature

Clear
07 - HCAMP Signature Date*

MonthDayYear
Date

LIABILITY FOR LOST, STOLEN, OR DAMAGED PERSONAL BELONGINGS

Sign and Acknowledge Below
I understand that should my child bring personal belongings to program (to include field trips), they do so at their own risk. ASAS is not responsible for lost, stolen, or damaged belongings.
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Signature

Clear
08 - Belongings Signature Date*

MonthDayYear
Date

ACKNOWLEDGEMENT OF VISITOR POLICY

Sign and Acknowledge Below
I understand that program/campus visitors must have legitimate business on campus or with the program and be expressly authorized by ASAS in advance. You may obtain a copy of the ASAS Visitor Policy from our website (WWW.ASASHAWAII.ORG/VISITORS).
Do you accept and acknowledge the statement above?*

YESNO
Parent/Guardian's Signature

Clear
09 - Visitors Signature Date*

MonthDayYear
Date

UPLINK Registration Form

Uniting Peer Learning, Integrating New Knowledge (Funding Source)
STUDENT INFORMATION
Student's Full Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Student's Email Address
johndoe@aloha.com
Student's School*
Student's Gender*

MaleFemaleOther
What is your students CURRENT grade? (As of Q1 24-25 SY)*
FAMILY INFORMATION
Parent/Guardian 1's Full Name*
Parent/Guardian 1's Address*

Street Address

Street Address Line 2

CityState

Zip
Parent/Guardian 1's Email Address*
johndoe@aloha.com
Parent/Guardian 1's Phone Number*
Please enter a valid 10-digit phone number.
Parent/Guardian 2's Full Name*
Parent/Guardian 2's Address*

Street Address

Street Address Line 2

CityState

Zip
Parent/Guardian 2's Email Address*
johndoe@aloha.com
Parent/Guardian 2's Phone Number*
Please enter a valid 10-digit phone number.
EMERGENCY INFORMATION
Emergency Contact's Full Name*
Emergency Contact's Relationship*
Emergency Contact's Phone Number*
Please enter a valid 10-digit phone number.
Parent/Guardian's Signature*

Clear
10 - UPLINK Signature Date*

MonthDayYear
Date

Enrollment Statement

Child and Adult Care Food Program (CACFP - FREE Meal/Snack during program)
ASAS Hawaii is partnering with the Hawaii Foodbank and the USDA Child and Adult Card Food Program (CACFP) to provide healthy food/snack to each student attending the after-school program. In order to receive this food/snack, you must complete and return the following CACFP Enrollment Statement. If you do not complete the form, unfortunately your child will not receive the provided food/snacks.
STUDENT INFORMATION
Student's Full Name*

First NameLast Name
Dietary Modifications Required*

NOYES
Dietary Modifications Description
Student's Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
Student's Race (Check all that apply)*

American Indian or Alaska NativeAsianNative Hawaiian or Other Pacific Islander (including Chuukese, Marshallese, Samoan, etc.)Black or African AmericanWhite
Parent/Guardian's Signature*

Clear
11A - CACFP Signature Date*

MonthDayYear
Date
11B - CACFP Signature Date*

MonthDayYear
Date

AFTER‐SCHOOL ALL‐STARS HAWAII CONCUSSION MANAGEMENT
Aloha After‐School All‐Stars Hawaii (ASAS) Parents and Guardians,

In order to provide your student athlete with the safest possible experience in our programs, ASAS practices strict adherence to concussion protocols. We see it as duty to inform students/parents/guardians of the risks associated with brain injuries as well as to provide information about an online training resource for you to stay informed about brain injuries, specifically concussions and the Hawaii Concussion Law.
What is Hawaii Concussion Law?
Hawaii Concussion Law ACT 262 includes:
- Education of parents, athletes, school staff and administrators and sports officials
- Includes youth sports from 11 years old and above.
- Annual training of coaches.
- Mandatory immediate removal of the athlete when a concussion is suspected.
- Need for clearance to return to play by a licensed health care provider trained in concussion management.
- Return to learn and gradual return to play protocols.
We would like to take this oppurtunity to inform you about an information resource and strongly suggest you take the time to become knowledgeable about brain injuries and concussion protocols.

Please find below a link to the Hawaii Concussion Awareness Management Program educational course for parents. You will find this resource helpful in ensureing you and your student-athlete make informed decisions about staying safe in relation to concussions and potential brain injuries.

On completion of the course you will receive a downloadable certificate.
Brain Space Training Course for Parents:
https://hawaiiconcussion.com/info?module=500.1&role=6
Should be Empty:

AFTER-SCHOOL ALL-STARS HAWAII REGISTRATION FORM

KALĀKAUA ALL-STARS * 808.371.4241 * KALAKAUA@ASASHAWAII.ORG

STUDENT INFORMATION

FAMILY CONTACT INFORMATION — Please Provide 2 Different Contacts

MEDICAL INFOMATION

DISMISSAL - STUDENTS ARE RELEASED PROMPTLY AT THE END OF PROGRAM

ACKNOWLEDGEMENT OF STUDENT PICK-UP

BEHAVIOR AND ATTENDANCE POLICIES FOR PROGRAM

PARENT LIABILITY/PARENT AUTHORIZATION

CONSENT FOR TREATMENT

PARENTAL CONSENT TO ACCESS REPORT CARDS AND OTHER SCHOOL DATA

PARENTAL CONSENT FOR PHOTOGRAPHS

CONCUSSION MANAGEMENT ACKNOWLEDGEMENT

LIABILITY FOR LOST, STOLEN, OR DAMAGED PERSONAL BELONGINGS

ACKNOWLEDGEMENT OF VISITOR POLICY

UPLINK Registration Form

STUDENT INFORMATION

FAMILY INFORMATION

EMERGENCY INFORMATION

Enrollment Statement

STUDENT INFORMATION

AFTER‐SCHOOL ALL‐STARS HAWAII CONCUSSION MANAGEMENT

What is Hawaii Concussion Law?

Hawaii Concussion Law ACT 262 includes:

Brain Space Training Course for Parents: