One moment please...
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
Contact Information
Child's Name
*
First Name
Last Name
Child/Client's birthdate
*
(mm/dd/yyyy)
Child's Phone Number
Child's Email (to use for google calendar tutoring appointments)
Verify Email
School
*
Grade
*
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
City
State
State/Province
ZIP/Postal Code
Country
Emergency Contact's Name
*
First Name
Last Name
Emergency Contact's Phone Number
*
Background information
Child 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
American Indian
Black
Cambodian
Caucasian (Not Portuguese)
Chinese
Filipino
Hawaiian (Full, Part)
Japanese
Korean
Laotian
Marshallese
Micronesian
Mixed (Not Hawaiian)
Other
Other Asian
Other Pacific Islander
Portuguese
Puerto Rican, Hispanic
Samoan
Tongan
Unknown
Vietnamese
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 your child have any preferred pronouns?
What is your child's barrier toward their educational, career, or cultural goals?
*
Has your child 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.
*
What services are you hoping to get help with this year?
*
How did you hear about us/this program?
*
Does your child 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.