General Liko Registration

Liko provides educational assistance to youth ages 5-24 who need additional assistance in meeting their educational goals.

Educational assistance includes, but is not limited to:

Educational Personal Plans
Small group or Individual Tutoring
Assistance in finding the right curriculum for those who are choosing their own in homeschool methods
Assistance with communicating with schools, teachers, and others involved in participants’ educational goals
Additional resources for parents

Spaces are limited. Priority participants include:

Youth looking for additional help in gaining their GED or HISET diploma
Youth who have had difficulty in their previous school setting and needing more individualized help
Youth who have been diagnosed with learning differences, behavioral disorders, or mental health diagnosis

This form is also utilized for any activities with Maui Hui Malama participants and their parents/caretakers.

Contact Information

Participant's Name *

First Name

Last Name

Participants's birthdate *

(mm/dd/yyyy)

Participant's Phone Number

Verify Email

School - n/a if not applicable *

Grade *

Please type n/a if this doesn't apply

Parent/ Guardian's Name *

First Name

Last Name

Parent/Guardian's Email *

Verify Email *

Parent/Guardian's Phone Number *

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Emergency Contact's Name - Please do not use the same person that is listed above *

First Name

Last Name

Emergency Contact's Phone Number- Please do not use the same person listed above *

Background information

Participant's Gender at Birth *

Female

Male

Gender Identity (for grant reporting) *

Maui Hui Malama is partly funded by the state, so we are required to ask this question for data reporting.

Female

Male

Gender Diverse

Mahuwahine/Mahukane

Other

Sexual Orientation (for grant reporting) *

Maui Hui Malama is partly funded by the state, so we are required to ask this question for data reporting.

Straight

Lesbian

Gay

Bisexual

Other

Public Assistance - (for grant reporting) *

Maui Hui Malama is funded and requires us to ask this question. My keiki receives

Free/Reduced Lunch

SNAP/EBT

TANF

Med Quest

HUD

ALICE (Assets Limited, Income Constrained, Employed) You earn above the Federal Poverty Level (FPL) so you don't qualify for government assistance but you make less than what's needed to afford basic essentials. There is no room for emergency expenses.

None

Geographic Area *

Central Maui

East Maui

Lana`i

Moloka'i

Other

South Maui

Upcountry

West Maui

Ethnicity - (for grant reporting) *

Please select all that apply based on these options

African American

Asian (Chinese, Japanese, Filipino, etc.)

Caucasian

Hawaiian / Part Hawaiian

Hispanic (Guatemalan, Mexican, Puerto Rican, etc.)

Other

Pacific Islander (Marshallese, Samoan, etc.)

Does participant have any preferred pronouns?

What barrier does the participant have toward their educational, career, or cultural goals? If you are registering yourself please type n/a *

Has participant been diagnosed with a behavioral disorder, mental health diagnosis, or learning difference? If yes, please explain what the disorder or diagnosis is AND what works well for them. If you are registering yourself please type n/a *

What services are you hoping to get help with this year? If you are registering yourself please type n/a *

How did you hear about us/this program? *

Does the participant have any known allergies? *

Agreements

Liability Release *

I hereby release, hold harmless, and indemnify Maui Hui Malama, its Board of Directors, employees and staff, from and against all claims, including but not limited to claims for property damage and/or personal injuries arising out of my child’s participation in MHM’s group, activities, or the rendering of any medical treatment. I understand that MHM will make reasonable attempts to notify me or the emergency contact as soon as possible in the event of illness or injury to my child to obtain authorization to administer necessary medical treatment. I further give consent to MHM to secure and authorize such medical treatment if MHM is unable to speak with me or the emergency contact for the above named child while under this supervision. I also agree to pay all costs and fees contingent upon receiving emergency medical care or treatment as secured or authorized under this content.

I agree

Release of Information *

I hereby release Department of Education and any school or educational entity to release educational information that pertains to my child or me. I also authorize Department of Education and or any other institution to release any other pertinent information including transcript records to Maui Hui Malama and to communicate by telephone, paper, or electronic format.

I agree

Electronic Equipment Agreement *

I understand that any electronic equipment that has been provided as a loaner is done so for the purpose listed in my child's personal plan. Should there be any damage to the equipment I take responsibility of the cost to replace the equipment. I understand that the equipment must be returned upon completion of the personal plan needs unless otherwise agreed upon in writing with Maui Hui Malama.

I agree

Media Release

I hereby give permission for Maui Hui Malama to use my or my child’s photo in but not limited to promotional materials including brochures, video, website, press release, TV, or radio ads.

I agree

Subsrcibe to Maui Hui Malama

By checking here I agree to receive emails, mail, and phone calls on information regarding this program as well as other information related to Department of Education, any school, and any educational entity and Maui Hui Malama

I agree

Legal Guardian *

I confirm I am the legal guardian of the participant listed above or 18 years or older.

I agree

Please type full name of legal guardian electronically signing this form.