Fall Break | PC Afterschool Hula

Fall Break is
Oct 7th - 11th

REGISTRATION FORM for FALL BREAK 2024 PROGRAM
for regular school year after school program registration, go here

Student Last Name

Student First Name

Grade (K-6)

RATES (Customize Schedule Below)
FULL DAY 7:00a-6:00p: $35 / DAY

A.M. HALF 7:00a-12:30p: $20 / DAY

P.M. HALF 12:30p-6:00p: $20 / DAY

WEEK-LONG, ALL-DAY PROGRAM

Along with daily AM/PM hula and indoor play/activity stations & outdoor playground/field PE, each day will have themed features:

Cooking Creations and Arts & Craft Projects:

MON: Baked Savory Appetizers and Hi-Contrast Concentric Paint Art

TUE: Local Asian Favorites and Mosaic Glass Tile Ceramic Coasters

WED: Comfort Food Classics and Making/Learning Maori Poi Balls

THU: Americano Italiano and Hand-Crafted Ironwood Keychains

FRI: Delectable Desserts and Mixed-Material Metal Wind Chimes

Outdoor Adventures and DIY Treats w/ Themed Story/Sharing:

MON: Sports Stations (pickleball, volleyball, hockey, baseball, soccer, and basketball) and DIY Sundaes (S/S theme: Bring the Funny)

TUE: Swimming (Walking Field Trip over to swim @ Pearl City District Pool) and DIY S'mores (S/S theme: Incredible Island Tales)

WED: Team Challenges (Build-A-Survival-Shelter, Group Games, and Puzzle/Scavenger Races) and DIY Sherbet (S/S theme: Cool Travels)

THU: Wacky Science (Explosive, Hands-on, Best-Done-Outdoors Experiments) and DIY Shakes (S/S theme: Awesome Inventions)

FRI: Fun in the Sun (Water Play, Obstacle Courses, Kite Flying, and Sledding) and DIY Smoothies (S/S theme: Perfect & Imperfect Pets)

Download PDF of the full Fall Program Schedule w/ Daily Activity Times HERE

ADD-ON LUNCH OPTION

Yes, add-on Mon lunch for $3

Yes, add-on Tue lunch for $3

Yes, add-on Wed lunch for $3

Yes, add-on Thu lunch for $3

Yes, add-on Fri lunch for $3

Will pack home lunch (AM half) or won't need lunch (PM half)

Daily Lunch Menu (Fixed Entrée & Veggies):

MON: Spaghetti w/ Meatballs & Crudités Veggies w/ Dressing

TUE: Flame-Grilled Cheeseburgers w/ French Fries & Coleslaw

WED: Hot Dog on a Bun w/ Tots & Carrot/Cucumber Potato Salad

THU: Spam Fried Rice w/ Lil' Smokies & Steamed Shelled Edamame

FRI: Mac and Cheese w/ Chicken Nuggets & Buttered Corn/Peas

Served with Drink, Side, and Fruit:

Milk or Juice | String Cheese or Gogurt | Apple or Banana or Orange

OTHER IMPORTANT INFO:

DROP-OFF is from 7:00 am @ Rm 22 and PICK-UP is until 6:00 pm @ Rm 22 or the front lot (after 4:45 pm). All indoor activities will be in Rm 22, hula will be on the outdoor stage (if it rains, it will be in the cafeteria), and outdoor play will be on the Diamond Head & Ewa playgrounds/fields, courts, or off-site as noted on the schedule. Please have your child bring a water bottle and wear comfy clothes/footware (whatever they'd wear to a park). They do not need to bring a backpack. We have colored tote bags, which we'll hang outside the room every day so each child can hang their things up when they arrive (i.e. snacks, sunscreen, home lunch, shoes on sports day, towel on swim day, etc.), and also store their completed crafts so everything is easy to find at the end of the day. Note that we'll provide PM snacks and sunscreen so they don't have to bring anything else unless they have specific snack/medical/other needs.

PARENT/GUARDIAN INFORMATION

Parent/Guardian Last Name

Email

Parent/Guardian Last Name

Email

Parent/Guardian First Name

Primary Phone #

Secondary Phone #

Parent/Guardian First Name

Primary Phone #

Secondary Phone #

ADDITIONAL INDIVIDUALS AUTHORIZED FOR PICK-UP

I understand that my child will only be released to parents/guardians and pre-authorized individuals.

Name

Relation to student:

Name

Relation to student:

Name

Relation to student:

EMERGENCY CONTACT INFORMATION

In the event the parents/guardians cannot be reached, who is the next person(s) to contact?

NAME

PHONE

NAME

PHONE

PEDIATRICIAN'S NAME

PHONE

Pediatricians will only be contacted for medical decisions if parents/guardians cannot be reached.

I give my consent for appropriate action to be taken for my child's well-being.

I understand I am financially resposible for ambulance transport and hospital charges incurred on my child's behalf in a warranted medical emergency.

ALLERGIES / MEDICATIONS / MEDICAL CONDITIONS

TERMS & CONDITIONS

ATTENDANCE: I understand that I need to give notice via phone, text, or email if my child will be absent or tardy so the program can adjust accordingly.

ILLNESSES: If my child is noticeably ill (presenting with a fever, Covid symptoms, etc.), I understand that I or my emergency contacts may be asked to take my child home early, for their well-being and that of their peers.

PICK-UP: I understand that I must pick up my child no later than 6:00p, and that I will give notice by phone or text if I will be late. If my child is not picked up by 6:30p, I give consent for my child to be driven to a new safer pick-up location (i.e. nearby open public library or shopping center) if the school lot becomes deserted or otherwise unsafe.

TUITION: I agree to pay the costs for all fall break program days selected before the first day of fall break.

RULES: My child and I understand that it is my child's responsibility to follow all rules, as they are there for their safety as well as that of their peers, and that continued disregard for rules may result in dismissal.

I understand and agree to all the terms & conditions listed above.

WAIVER, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT

I understand that my child's participation in the activities offered by Pearl City Afterschool Hula, LLC is not without known and unknown risks, and that this agreement applies to all instances of my child's participation.

I understand that Pearl City Afterschool Hula, LLC is in full compliance with all school and state liability insurance requirements, and that they have provided the school with their Certificate(s) of Insurance per state regulations.

I understand and allow for the responsible videotaping and photography of my child engaged in hula and other related program activities by Pearl City Highlands Elementary and Pearl City Afterschool Hula, LLC for online, digital, print, or social media sharing, without compensation, hereby releasing interest in said media for which I am giving permission.

I understand that the State of Hawaii and Department of Education requires liability waivers and indemnification agreements from the participants of Pearl City Afterschool Hula, LLC's activities that take place on and off Pearl City Highlands Elementary School grounds, as applied to all instances of my child's participation in said activities, as well as any separately related off-campus measures that may be taken in regard to my child's safety or well-being.

Indemnification Statement: The undersigned individual, family members, personal representatives, agents, and successors, for and in consideration of the State of Hawaii Department of Education permitting and allowing the use of the designated school rooms, buildings, and/or facilities jointly and severally agree(s) to indemnify and save harmless the State of Hawaii Department of Education and Pearl City Afterschool Hula, LLC, against any and all loss, liability, demands, claims, suits, action or proceedings of every name, character and description which may be incurred by or brought against the State of Hawaii Department of Education and/or Pearl City Afterschool Hula, LLC for or an account of any injuries or damages to any person or property received or sustained by any person, directly or indirectly, by or in consequence of the participation of said activities and use of the school facilities/grounds.

Electronic Signature (type your first and last name)

I am the child's parent/guardian, authorized to acknowledge and accept all terms on this form.

Acceptance and Acknowledgement

By checking this box, I hereby certify my typed electronic signature and assert my full understanding and agreement to the above statements.

The entire fall break program payment will be due in full before the start of the fall break program. Your signature below certifies that you understand and agree to your payment responsibilities.

How will you be paying for the fall break program?

Please email me an online credit card invoice (via Square® online payments)

Please email me a PayPal invoice

Please email me a Venmo invoice

I will pay by credit card, in person, no later than the week BEFORE fall break starts

I will pay by check, in person, no later than the week BEFORE fall break starts

I will pay in cash, in person, no later than the week BEFORE fall break starts

REGISTRATION FORM for FALL BREAK 2024 PROGRAM
for regular school year after school program registration, go here

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

In the event the parents/guardians cannot be reached, who is the next person(s) to contact?

ALLERGIES / MEDICATIONS / MEDICAL CONDITIONS

TERMS & CONDITIONS

WAIVER, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT

PAYMENT

Due to limited spots, registration is open to students currently enrolled in After School Hula only.

REGISTRATION FORM for FALL BREAK 2024 PROGRAM for regular school year after school program registration, go here

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

In the event the parents/guardians cannot be reached, who is the next person(s) to contact?

ALLERGIES / MEDICATIONS / MEDICAL CONDITIONS

TERMS & CONDITIONS

WAIVER, RELEASE OF LIABILITY, AND INDEMNITY AGREEMENT

PAYMENT

Due to limited spots, registration is open to students currently enrolled in After School Hula only.

REGISTRATION FORM for FALL BREAK 2024 PROGRAM
for regular school year after school program registration, go here