KOYD/RISE PROGRAM – Keaukaha Canoe Club – Hilo Hawaii Paddling Club on the Big Island

If you have minors who are interested in joining our youth program run by Keaukaha One Youth Development (KOYD), please fill out the application and HCRA waiver for each person. Youth paddling programs typically start in late March or early April each year.

2023-2024 PROGRAM APPLICATION FORM

Dear Parent/Guardian and Applicant,

Thank you for your interest in the Keaukaha One Youth Development—RISE 21st Century Out-of-School Time Program. Please fill out this application form completely. If you have any questions regarding this application form, please contact the Executive Director, Keahi Warfield at (808)895-8666 or by email at keahi.koyd.rise@gmail.com.

Applicant’s Legal Name

Legal First Name: Legal Middle Name: Legal Last Name: Preferred Name:
Sex: (Check One) Male
Female

If the applicant is under 8 years old, parental assistance and a swim test is required. Birthdate: MM/DD/YYYY Applicant’s Email Address:

HOME ADDRESS: Home Street Address: Home City Address: Home State Address: Home ZIP Address:

MAILING ADDRESS (Leave blank unless different from Home Address): Mailing Street Address: Mailing City Address: Mailing State Address: Mailing ZIP Address:

Contact Numbers and Email Addresses Home Phone: Best Contact Hours: Mother's Cell Phone: Father's Cell Phone: Mother's Work Phone: Father's Work Phone: Mother's Email: Father's Email:

School Information Current School Enrolled: School Phone: Grade: Teacher:

Ohana Information -- Check appropriate box.
FATHER
Birth Father
Step Father
Adoptive Father
Male Legal Guardian**
First Name: Middle Name: Last Name:
Occupation: Employer:

MOTHER
Birth Mother
Step Mother
Adoptive Mother
Female Legal Guardian**
First Name: Middle Name: Last Name:
Occupation: Employer:

Birth Parents' Status
Parents Married
Parents Legally Separated**
Parents Separated
Parents Divorced**
Widowed (birth father deceased)
Widowed (birth mother deceased)
Never Married

Who has Physical Custody of the Applicant?
Name(s): Relationship(s):
**If legally separated, divorced or legal guardian, please email a copy of the divorce decree or custody order to clarify the legal custodial status of the applicant.

Who is living in Applicant’s Primary Household?: (check all that apply)
Birth Father
Step Father
Grandfather
Brother(s)
Birth Mother
Step Mother
Grandmother
Sister(s)
Adoptive Parent(s)
Legal Guardian(s)
Aunt/Uncle
Other People Living At Home:
Total Number of People Living in Applicant’s Primary Household:
Person(s) Authorized to Pick Up Your Child (person must show picture ID):
Person 1 Name: Person 1 Relationship: Person 1 Phone #
Person 2 Name: Person 2 Relationship: Person 2 Phone #
Person 3 Name: Person 3 Relationship: Person 3 Phone #

HEALTH INFORMATION

Is your child under medical care or taking any medication(s)?
YES
NO

If yes, please check all of the following conditions that your child has and indicate if medication needs to be dispensed during program hours?
Has Bee Sting Allergy
Allergy Epi-pen Needed
Other Allergy:
Has Asthma
Inhaler Needed
Other Special Needs:
Has Diabetes
Insulin Needed
Other Conditions:
Vision or Hearing Issues
Glasses or Hearing Aids Needed

Physician’s Name Physician's Phone Number
Health Insurance:

In case of an emergency, please list three contacts:
Emergency Contact 1 Name: Emergency Contact 1 Relationship: Emergency Contact 1 Phone #
Emergency Contact 2 Name: Emergency Contact 2 Relationship: Emergency Contact 2 Phone #
Emergency Contact 3 Name: Emergency Contact 3 Relationship: Emergency Contact 3 Phone #

PROGRAM INFORMATION & POLICIES

ATTENDANCE

The RISE 21st Century Out-of-School Time Program is a year-round program that begins in September and runs through the last week of July. The program offers two separate facilities. The RISE main facility is located at 67 Keokea Loop and our outdoor cultural site is located at Palekai (Breakwall) in Keaukaha, Hilo, Hawaii. Refer to our website: www.koyd.org for our monthly calendar for daily programming and planned activities. Student success is dependent on the frequency of participation from your child. Students enrolled in this program are expected to attend at least three times per week. We recognize that there may be circumstances that require your child’s absence or release.

DISCIPLINE POLICY

The purpose of a discipline policy is to facilitate a positive Out-of-School Time climate where students and staff are safe and secure. If program staff determines a child’s behavior is in any way disruptive to the safety and security of others, the parent/legal guardian(s) will be notified. If such behavior does not improve, the RISE 21st Century Out-of-School Time Program reserves the right to dis-enroll the child from the program at any time.

PICK-UP POLICY

Please refer to the monthly calendar for start times and pick-up times. Please respect the time of our staff of the RISE 21st Century Out-of-School Time Program and call ahead of time if you will be late to start or pick-up. The RISE 21st Century Out-of-School Time Program reserves the right to dis-enroll your child shall the continuance of late pick-up without prior notification occur.

MEDICATION POLICY

If your child becomes sick or is injured during program hours of operation, you will be contacted immediately for pick-up. Medicine will not be administered without written permission from the parent or legal guardian.

Please read and sign below:

I agree that I have read and filled out this application as completely and accurately as possible. I have read, understand, and acknowledge the RISE 21st Century Out-of-School Time Program Policies attached. In addition, I have and read and understand that the RISE 21st Century Out-of-School Time Program is made possible through donations and grants provided through Federal, State, and Private sectors. I give permission for the RISE 21st Century Out-of-School time staff to review and utilize my child’s academic files for purposes of analyzing program effectiveness and reporting to funding sources.

Parent/Guardian Name: Date:

A copy will be emailed to you and KOYD for your records. After submitting, you'll need to sign a waiver for this applicant for Hawai'i Canoe Racing Association (HCRA).
If you would like to enter information for another child, just go BACK in your browser and change the data and submit again AFTER filling out the next HCRA waiver.

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