Please complete the application below. Required fields are marked with an *. This application is designed for use with a standard keyboard. Avoid using all capitals letters when entering data. Use capitals only when appropriate such as the first letter of proper names.
STUDENT INFORMATION
* = required fields
* First Name
 * Last Name
Middle Initial
 * Gender:
male   female
* Birth Date (MM/DD/YY)
 Student E-Mail:

Student ID (Iolani Students Only) *US Citizen
Yes   No

*Current School School Next Year *Entering Grade

To See a List of Courses? Click here

Please enter the course code of the courses you wish to register for below.

* Course Code:

PARENT/GUARDIAN INFORMATION

FATHER
Title
 First Name
Last Name
Daytime Phone
Cell Phone
Email
MOTHER
Title
 First Name
Last Name
Daytime Phone
Cell Phone
Email

SIBLINGS ATTENDING 'IOLANI SCHOOL
    Name
1. 		Grade
2.


PREFERRED MAILING ADDRESS
*Name
*Address (Street)
 *Parent E-mail
*City
 *State
 *Zip Code

NON-HAWAII RESIDENT (International, Mainland students or Hawaii Residents not currently residing in Hawaii)
Hawaii Address (Street)
   Hawaii Phone
City
 State
 Zip Code

All Non-Hawaii Resident students and Hawaii students not currently residing in Hawaii are required to submit the 'Iolani Summer School Health Form completed by a US licensed physician. TB test must be done within 6 months prior to the start of Summer School. The Health Form may be downloaded from the Summer Programs website page. Although students may register online, their registration will not be completed until the Summer Program Office receives the Health Form.

MEDICAL EMERGENCY AUTHORIZATION

*Primary Contact Person:
 *Day Phone or Cell:
Secondary Contact Person:
 Day Phone or Cell:
Person (other than parents) authorized to take student from facility:
 		Day Phone or Cell:

PRIMARY PHYSICIAN
Name
Address (Street)
 Phone
City
 State
 Zip Code

  Hawaii Insurance Plan
   Subscriber No.

MEDICAL INFORMATION

Special medical conditions and allergies of all types that should be shared with faculty and staff for the purpose of safety and optimal learning are as follows:
  Please list medical conditions, allergies, and name/dosage of medications:
It is 'Iolani's policy to make its programs, services, and activities accessible to a "qualified person with a disability," unless (1) there is a fundamental alteration in the nature of the program or service. (2) there is an undue burden, or (3) a "qualified person with disability" poses a direct threat to him or herself, or to others.
*Does your child have a documented disability that requires an accommodation to attend an 'Iolani summer program?
Yes   No
  If YES, please describe what accommodation(s) the applicant requires.:
'Iolani School maintains health records for each student, including the health forms routinely submitted. In certain situations, it will be necessay to share the information contained in the health records with the faculty and/or staff of the school, when, in the School's judgement, such disclosure is required for the student's health or educational needs. In emergency situations involving the health of the student, the School may disclose such information to other parties.
*We authorize 'Iolani School personnel to contact our physician and to arrange for appropriate medical care if we are not available at the time of an emergency.
Yes   No
  Name of Preferred Hospital or Clinic
*We understand that the School may not be able to transport our child to the preferred facility in emergency situations. We also understand 'Iolani School's medical information statements as above.
Yes   No
*Photographic Consent: "Iolani staff regularly photographs students in classroom activities and on compus for use in promotional material either in print or on the 'Iolani School Website. It is 'Iolani's policy not to directly associate a child's name with a photograph of the child. I give permission for 'Iolani School to use said Student's photo for school purposes.
Yes   No
*Internet Use: Said Student to have access to the Internet and/or email account designed for educational purposes. I understand that it is impossible for 'Iolani School to eliminate access to all controversial materials, and will not hold 'Iolani responsible for material acquired or strangers met on the network. Further, I accept full responsibility for supervision if and when said Student's computer use is not in a school setting. This privilege may be revoked by the computer system administrator or Summer Director if use is abused by the student.
Yes   No
*I certify that the above statements are true to the best of my knowledge. I agree to furnish proof and documentation as requested by 'Iolani. I acknowledge that failure to disclose any requested information, or providing inaccurate information may result in the disqualification or disenrollment of my child without refund.
Yes   No
*I certify that I have reviewed the 'Iolani Summer School Catalog. I agree to accept 'Iolani's Procedures, Rules and Regulations as contained in the 'Iolani Summer School Catalog. I also agree to the photographic use consent and internet use statement as stated above in this form unless noted otherwise.
Yes   No
  Exceptions for consent and release: