One moment please...
AT&T Homework Gap Hotspots
*
I verify that my child qualifies for this hotspot because my child is: 1) in foster care 2) experiencing homelessness 3) speaks English as his/her second language 4) has a disability 5) is eligible for the Migrant Education Program or 6) an at-risk students who is disconnected from traditional education opportunities.
Contact Information
*

First Name
Last Name
*

*

*

First Name
Last Name
*

*

*

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
Background information
*
*

(mm/dd/yyyy)
*
*
Please select all that apply based on these options
*
Please select all that apply based on these options
*

*

Please choose other programs you are interested in us contacting you about. You may also visit our website mauihui.org to learn more.
Agreements
*
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.
*
COVID-19 SAFETY INFORMATION: While participating in events held or sponsored by the Maui Hui Malama (MHM) “social distancing” must be practiced and face coverings worn at all times to reduce the risks of exposure to COVID-19. Because COVID-19 is extremely contagious and is spread mainly from person-to-person contact, MHM has put in place preventative measures to reduce the spread of COVID-19. However, MHM cannot guarantee that its participants, volunteers, partners, or others in attendance will not become infected with COVID-19. In light of the ongoing spread of COVID-19, individuals who fall within any of the categories below should not engage in MHM events and/or other face to face fundraising activities. By attending an MHM event, you certify that you do not fall into any of the following categories: 1. Individuals who currently or within the past fourteen (14) days have experienced any symptoms associated with COVID-19, which include fever, cough, and shortness of breath among others; 2. Individuals who have traveled at any point in the past fourteen (14) days either internationally or to a community in the U.S. that has experienced or is experiencing sustained community spread of COVID-19; or 3. Individuals who believe that they may have been exposed to a confirmed or suspected case of COVID-19 or have been diagnosed with COVID-19 and are not yet cleared as non-contagious by state or local public health authorities or the health care team responsible for their treatment. DUTY TO SELF-MONITOR: Participants and volunteers agree to self-monitor for signs and symptoms of COVID-19 (symptoms typically include fever, cough, and shortness of breath) and, contact MHM if he/she experiences symptoms of COVID-19 within 14 days after participating or volunteering with MHM. LIABILITY WAIVER AND RELEASE OF CLAIMS: I acknowledge that I derive personal satisfaction and a benefit by virtue of my participation and/or voluntarism with MHM, and I willingly engage in MHM events and/or other fundraising activities (the “Activity”). RELEASE AND WAIVER. I HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE ANY AND ALL LIABILITY, CLAIMS, AND DEMANDS OF WHATEVER KIND OR NATURE AGAINST THE MAUI HUI MALAMA AND ITS AFFILIATED PARTNERS AND SPONSORS, INCLUDING IN EACH CASE, WITHOUT LIMITATION, THEIR DIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AND AGENTS (THE “RELEASED PARTIES”), EITHER IN LAW OR IN EQUITY, TO THE FULLEST EXTENT PERMISSIBLE BY LAW, INCLUDING BUT NOT LIMITED TO DAMAGES OR LOSSES CAUSED BY THE NEGLIGENCE, FAULT OR CONDUCT OF ANY KIND ON THE PART OF THE RELEASED PARTIES, INCLUDING BUT NOT LIMITED TO DEATH, BODILY INJURY, ILLNESS, ECONOMIC LOSS OR OUT OF POCKET EXPENSES, OR LOSS OR DAMAGE TO PROPERTY, WHICH I, MY HEIRS, ASSIGNEES, NEXT OF KIN AND/OR LEGALLY APPOINTED OR DESIGNATED REPRESENTATIVES, MAY HAVE OR WHICH MAY HEREINAFTER ACCRUE ON MY BEHALF, WHICH ARISE OR MAY HEREAFTER ARISE FROM MY PARTICIPATION WITH THE ACTIVITY. ASSUMPTION OF THE RISK. I acknowledge and understand the following: 1. Participation includes possible exposure to and illness from infectious diseases including but not limited to COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; 2. I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19, even if arising from the negligence or fault of the Released Parties; and 3. I hereby knowingly assume the risk of injury, harm and loss associated with the Activity, including any injury, harm and loss caused by the negligence, fault or conduct of any kind on the part of the Released Parties. MEDICAL ACKNOWLEDGMENT AND RELEASE. I acknowledge the health risks associated with the Activity, including but not limited to transient dizziness, lightheaded, fainting, nausea, muscle cramping, musculoskeletal injury, joint pains, sprains and strains, heart attack, stroke, or sudden death. I agree that if I experience any of these or any other symptoms during the Activity, I will discontinue my participation immediately and seek appropriate medical attention. I DO HEREBY RELEASE AND FOREVER DISCHARGE THE RELEASED PARTIES FROM ANY CLAIM WHATSOEVER WHICH ARISES OR MAY HEREAFTER ARISE ON ACCOUNT OF ANY FIRST AID, TREATMENT, OR SERVICE RENDERED IN CONNECTION WITH MY PARTICIPATION IN THE ACTIVITY. As a participant, volunteer, or attendee, You recognize that your participation, involvement and/or attendance at any Maui Hui Malama fundraising event or activity (“Activity”) is voluntary and may result in personal injury (including death) and/or property damage. By attending, observing or participating in the Activity, You acknowledge and assume all risks and dangers associated with your participation and/or attendance at the Activity, and You agree that: (a) the Maui Hui Malama, Inc. (b) the property or site owner of the Activity, and (c) all past, present and future affiliates, successors, assigns, employees, volunteers, vendors, partners, directors, and officers, of such entities (subsections (a) through (c), collectively, the "Released Parties"), will not be responsible for any personal injury (including death), property damage, or other loss suffered as a result of your participation in, attendance at, and/or observation of the Activity, regardless if any such injuries or losses are caused by the negligence of any of the Released Parties (collectively, the "Released Claims"). BY ATTENDING AND/OR PARTICIPATING IN THE ACTIVITY, YOU ARE DEEMED TO HAVE GIVEN A FULL RELEASE OF LIABILITY TO THE RELEASED PARTIES TO THE FULLEST EXTENT PERMITTED BY LAW.
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.
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 confirm I am the legal guardian of the participant listed above or 18 years or older.
*
When would you like to pick up your hotspot? our Maui Hui Makeke booth at the Sunday Market. Please choose one option from below.