ENROLLMENT FORMNew Student Enrollment FormStep 1 of 147%This form should take about 20 minutes to complete. To make the process smoother, you may have the following ready: Proof of age (birth certificate or passport) Parent/guardian photo ID. You can upload these documents in the form or bring them to our office at a later time. You can complete this form on your phone or computer, and you may return later if needed.What is your child’s full legal name?(Required) First Middle Last What is your child’s date of birth?(Required) What is your child’s gender?(Required) Male FemaleWhich grade will your child be enrolling in for the upcoming school year?(Required) 6th Grade 7th GradeWhich country was your child born?(Required) USA OtherCountry of BirthDoes your child currently have a fixed, regular, and adequate nighttime residence?(Required) Yes NoIf no, the student may qualify for McKinney-Vento support.Has your child attended a Hawaii public school or public charter school before?(Required) Yes NoWhat school did your child most recently attend?Prior school attended, if not a Hawaii public schoolWhat grade is your child currently in?(Required) 5th Grade 6th GradeWhen did your child first attend school in the United States? (if applicable) If the student was not born in the U.S.What is your child’s home address?(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Hawaii ZIP Code Is your mailing address different from your home address? (if different than home address, please provdie it here) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your child Hispanic or Latino?(Required) Yes NoPlease select your child’s race or ethnicity (select all that apply)(Required) American Indian or Alaska Native Black Chinese Filipino Native Hawaiian Japanese Korean Portuguese Samoan White Guamanian/Chamorro Indo-Chinese Micronesian Other Asian Tongan Other Pacific IslanderStudent Primary Race (Which race or ethnicity best describes your child?)(Required) American Indian or Alaska Native Black Chinese Filipino Native Hawaiian Japanese Korean Portuguese Samoan White Guamanian/Chamorro Indo-Chinese Micronesian Other Asian Tongan Other Pacific IslanderWhat is the full name of the primary parent or guardian?(Required) First Last Is this parent or guardian Hispanic or Latino?(Required) Yes NoPlease select this parent or guardian’s race or ethnicity(Required) American Indian or Alaska Native Black Chinese Filipino Native Hawaiian Japanese Korean Portuguese Samoan White Guamanian/Chamorro Indo-Chinese Micronesian Other Asian Tongan Other Pacific IslanderParent Primary Race(Required) American Indian or Alaska Native Black Chinese Filipino Native Hawaiian Japanese Korean Portuguese Samoan White Guamanian/Chamorro Indo-Chinese Micronesian Other Asian Tongan Other Pacific IslanderWhat is the marital status of the parent(s)/guardian(s)?(Required)MarriedDivorcedSeparatedSingleDoes this person have legal custody of the student?(Required) Yes NoAre there any custody or legal arrangements we should be aware of?(Required) Yes NoPlease briefly describe the situation (for example: shared custody, restricted pickup, court order, etc.)Primary parent/guardian HOME address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If different than student's main address that you entered before.Primary parent/guardian MAILING address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If different than student's main address that you entered before.What is the best phone number to reach this parent or guardian?(Required)Home PhonePrimary Parent/Guardian Work PhoneWhat is this parent or guardian’s email address?(Required) Please provide an email address that is your primary email address and you frequently check.Is this parent/guardian a member of the Armed Services, National Guard, or Reserves?(Required) Yes NoWhat is their military status?Active DutyNational GuardReserveTitle 10 OrdersWhich branch do they serve in?Air ForceArmyNavyMarine CorpsCoast GuardSpace ForceNOAAUSPHSIs this parent/guardian deployed? Yes NoDoes this parent or guardian work for the federal government or on federal property? Yes NoIs there a second parent or guardian to add?(Required) Yes NoWhat is their full name? First Last What is their relationship to the student?Does this person have custody of the child? Yes NoAddress of the Second Parent/Guardian Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number of the Second Parent/GuardianEmail Address of the Second Parent/Guardian Is this parent/guardian a member of the Armed Services, National Guard, or Reserves? Yes NoWho should we contact in case of an emergency?(Required) First Last What is their relationship to your child?(Required)What is their phone number?(Required)Emergency Contact 2 full name(Required) First Last Relationship to the Student(Required)Emergency Contact 2 Phone(Required)Emergency Contact 3 full name First Last Emergency Contact 4 full name First Last Relationship to the StudentEmergency Contact 4 PhoneDoes your child have health insurance?(Required) Yes NoInsurance provider or QUEST planDoes your child have any medical conditions we should be aware of?(Required) Yes NoMedical conditions ADHD Asthma Autism Chronic cough/wheezing Hearing problems Seizures Blood disorders Diabetes Type I Heart condition Skin problems Bone/joint disorders Diabetes Type II High blood pressure Vision problems Cancer/Leukemia Genetic condition Metabolic disorder OtherOther Medical ConditionDoes your child have any allergies?(Required) Yes NoAllergy type Bee Sting Food (Please specify) Medications (Please specify) OtherPlease SpecifyReaction occurs by Skin Contact Inhalation Ingestion OtherOtherOther Health Concerns (if any)Will your child need medication administered at school? Yes NoWhat is your child’s healthcare provider’s name and phone number?Healthcare provider phoneDoes your child currently IEP/504 Plan?(Required)IEP stands for Individualized Educational Plan for students with learning disabilities. IEP 504 Plan NoneDoes any of the legal parents/guardians require interpretation or translation of information from your child’s school in your native language?(Required) Yes NoLanguage needed for interpretation or translationWhat language or languages are most used in your home, regardless of the language spoken by your child?(Required)What language did your child first acquire?(Required)Which language does your child use or understand most?(Required)Kūlia Academy may create or use photographs, audio, video, student work, and similar media of your child for school-related and promotional purposes. This may include the school website, newsletters, social media, yearbooks, events, and external media such as newspapers or television.Do you give permission for Kūlia Academy to use your child’s name, image, voice, or student work for these purposes?(Required) Yes NoKūlia Academy provides students with access to school-issued devices, internet, and digital learning platforms as part of its academic program, including coursework in technology, data science, and artificial intelligence. These tools are intended to support learning and must be used responsibly, safely, and for school-related purposes. Students are expected to follow school expectations, respect others, and use technology appropriately at all times. Students are not permitted to bring personal electronic devices to school, including cell phones, smartphones, tablets, or smartwatches. All technology used during the school day must be school-approved. Misuse of technology may result in loss of access or other school consequences. While the school takes steps to support safe use, families are responsible for supervising device use outside of school.Student Agreement(Required) I understand that I am expected to use school technology responsibly, respectfully, and for school-related purposes, and that personal electronic devices are not allowed at school.Parent/Guardian Agreement(Required) I understand that my child will use school-issued devices, internet, and digital learning platforms as part of instruction. I understand that my child may not bring personal electronic devices to school, including phones, tablets, or smartwatches. I understand that my child must follow school expectations when using technology. I understand that misuse of technology may result in consequences, including loss of access. I understand that I am responsible for supervising my child’s use of technology outside of schoolIf you have these documents ready, you can submit them here or provide digital/physical copies to our office later.Proof of age documentMax. file size: 256 MB.Birth certificate, passport, or other official proof of agePhoto ID(s) of Parent(s)/Guardian(s)Max. file size: 256 MB.Custody or guardianship documentsMax. file size: 256 MB.IEP document/504 PlanMax. file size: 256 MB.Please review your answers carefully before signing. By signing below, you confirm that the information provided is true and complete to the best of your knowledge.Parent/Guardian Signature(Required)Provide your name for signature. First Last Date(Required) Certification(Required) I certify that the information submitted in this enrollment form is accurate and complete.
