Application

Please fill out the form completely. The fields with red asterisks must be filled in. Contact us if you have any questions or concerns.

Last Name: *

First Name *

Date of Birth: *

Gender: *

Grade:

School:

E-mail Address: *

Street Address: *

Address Line 2:

City: *

State/Prefecture: *

Zip/Postal Code: *

Country *

Best Contact Number: *

Additional Phone Number:

Father/Legal Guardian Name (Last, First):

Best Contact Number:

Mother/Legal Guardian Name (Last, First):

Best Contact Number:

Primary Emergency Contact and phone 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 located HERE) *

YES
NO

Course: *

Voice part:

Technique Level on Instrument *

Music Theory Background (1=None 10=Knowledgeable): *

Knowledge of Chords on Instrument. (1=None 10=Advanced): *

Hobbies:

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Comments / Questions:

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