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下記の用紙にご記入の上、送信ください。赤印の部分は必須です。ご自身に当てはまらない部分はn/aとご記入ください。ご質問やご不明な点がございましたらお気軽にお問い合わせください。

Last Name: *
First Name *
Date of Birth: *
Gender: *
Grade:
School:
E-mail Address: *
Street Address: *
Address Line 2:
City: *
State: *
Zip Code: *
(B) Phone Number:
(H) Phone Number:
Cell Number: *
Participant resides with (for minors only):
Father/Legal Guardian Name (Last, First): *
Best Contact Phone Number: *
Mother/Legal Guardian Name (Last, First): *
Best Contact Phone Number: *
Primary Emergency Contact: *
Physician: *
Phone Number: *
Cell Number:
Please list any physical or other limitations that might hinder your childs participation:
In addition to the parents/legal guardians, I authorize the following people to pick up my child(ren) and/or be contacted in an emergency if the parent/legal guardian cannot be contacted. Include full name, relationship, home and cell numbers.

I authorize KE KULA MELE HAWAII O AKAKA to use the name and any video/photography/audio taken of my participant and/or myself at any time or in any manner in connection with its advertising, publicity and public relations programs. KE KULA MELE HAWAII O AKAKA may only use the video/photographs/audio and will not sell it to any 3rd parties or allow its use in any manner other than specified above. I will make no further claims. *
Yes No
I read, understand and accept the policies of Ke Kula Mele (POLICIES button located on left sidebar) *	YES NO
Course: *
Instrument: *
Voice part:
Technique Level (1=Beginner 10=Advanced): *
Music Theory Background (1=None 10=Knowledgeable): *
Knowledge of Chords on Instrument. (1=None 10=Advanced): *
Hobbies:
How did you find us?
Comments / Questions:



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