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2015-2016 ADMISSIONS CHECKLIST AND
IMPORTANT ENROLLMENT INFORMATION
IMPORTANT ENROLLMENT DATES
January 20, 2015 (ongoing thereafter): Returning Students and Preschool Siblings
February 2, 2015 (ongoing thereafter): New Military Preschoolers and Prekindergarten through Fourth Grade Siblings
February 17, 2015 (ongoing thereafter): Waitlisted Military Families (from previous school year)
March 2, 2015 (ongoing thereafter): New Military Families
April 1, 2015 (ongoing thereafter): New Civilian Families
AGE REQUIREMENTS
New students entering Navy Hale Keiki School must meet the following age requirements.
Preschool - 3 years old by 7/31/2015
Prekindergarten - 4 years old by 7/31/2015
Kindergarten - 5 years old by 7/31/2015
DUE AT TIME OF REGISTRATION (NEW AND RETURNING STUDENTS)
Completed NHKS Application and Registration Forms
BOTH PARENTS must sign the Tuition Agreement
Registration Fee ($175.00) and Tuition Deposit ($200.00)
Please be advised that incomplete applications will not be processed.
Students will not be eligible to attend until all applicable forms have been signed and submitted.
All new students will be scheduled for a screening once registration forms and fees have been received.
Returning students do not need to complete another screening.
DUE BY JULY 1, 2015 (NEW STUDENTS)
 Copy of student’s birth certificate
 Student Form 14 Health Record (or equivalent) - Physical examination must be performed within 12
months of student’s first day of attendance. If a physical examination cannot be completed prior to the
student’s first day, please provide a statement from your health care facility indicating the date of your
child’s appointment.
 TB skin test - performed within 12 months prior to student’s first day of attendance.
(A separate sheet is not necessary if your child’s Tuberculosis Exam is annotated on Form 14)
 Current immunization record (A separate sheet is not necessary if your child’s immunizations are annotated on Form 14)
 Previous School Records (Grades K-4 only if applicable) including Progress Reports, Test Scores, etc.
(If these are not available, please ensure you provide accurate previous school contact information on your enrollment form so
that we may request your student’s records. )
 Copy of Power of Attorney (Only if military spouse/sponsor is deployed or unable to sign)
 Copy of Dependant Care Certificate or Family Care Plan (Only for single parent or dual military families)
DUE BY JULY 1, 2015 (RETURNING STUDENTS)
***Returning students do not need to provide birth certificate, annually updated Form 14 or TB Clearance***
These documents are only necessary if there are changes in information.
Returning students entering Kindergarten must provide an updated immunization record listing their
Kindergarten shots.
WE ANTICIPATE FULL CLASSES. PLEASE DO NOT DELAY SUBMITTING YOUR APPLICATION.
REGISTRATION IS ACCEPTED ON A FIRST COME, FIRST SERVED BASIS.
NAVY HALE KEIKI SCHOOL
2015-2016 STUDENT APPLICATION/ENROLLMENT FORM
FOR OFFICE USE ONLY
Grade Level:
First Day:
Teacher:
Screening:
Checked ID
Known to me/returning
Signature of Witness:
Date:
STUDENT INFORMATION
Last Name:
Middle Name:
First Name:
Birthdate (MM/DD/YYYY):
T-Shirt Size:
XS
S
M
L
XL
Gender:
Male
Female
Ethnic Category of Student (Optional. Used for record keeping purposes to maintain nonprofit status.):
African American
Asian
Caucasian
Hispanic
Native American or Alaskan Native
Native Hawaiian or Other Pacific Islander
Other:
NOTICE OF NONDISCRIMINATORY POLICY
Navy Hale Keiki School does not discriminate on the basis of religion, race, color, national origin, sex, disability, age, height, weight, or familial status in its
admission, education programs, or other school administered activities.
CONTACT INFORMATION
Physical Address:
Number
Street
Apartment Number
City
State
Zip Code
Mailing Address (If different from above.):
Military Housing:
Add to Carpool List:
Yes
No
PARENT/GUARDIAN INFORMATION
MOTHER/GUARDIAN
FATHER/GUARDIAN
Dual Military:
Yes
No
Anticipated Rotation Date (Month/Year):
Last Name:
Home Phone: (
)
First Name:
Cell Phone: (
)
Email:
Work Phone: (
)
Status (Check all that apply.):
Employer/Command:
Branch of Service:
Marital Status:
Custody of Child:
Rate/Rank:
Married
Physical
ACT
RES
RET
HIANG
Divorced
Separated
Single
Educational
Child Lives with Parent/Guardian:
Yes
Last Name:
Home Phone: (
)
First Name:
Cell Phone: (
)
Email:
Work Phone: (
)
Marital Status:
Custody of Child:
Rate/Rank:
Married
Physical
No
Status (Check all that apply.):
Employer/Command:
Branch of Service:
DOD
ACT
RES
RET
HIANG
Divorced
Separated
Single
Educational
Child Lives with Parent/Guardian:
Yes
1
DOD
No
SIBLINGS ENROLLED AT NHKS
Name:
Grade:
Name:
Grade:
Name:
Grade:
EMERGENCY CONTACTS/CARPOOL
List two persons (other than parents/guardians) authorized to pick up your child. Please also indicate whether authorized persons are
designated for carpool pick-up and/or emergency pick-up.
Application cannot be process without at least two on-island emergency contacts listed.
It is the parent's/guardian's responsibility to notify the school of any changes.
Name:
Authorized as:
Emergency Contact/Pick-Up
Carpool
Emergency Contact/Pick-Up
Carpool
Emergency Contact/Pick-Up
Carpool
)
Phone 1: (
)
Phone 2: (
)
Phone 1: (
)
Phone 2: (
)
Does this contact live on island?
Name:
Authorized as:
Phone 2: (
Does this contact live on island?
Name:
Authorized as:
)
Does this contact live on island?
Name:
Authorized as:
Phone 1: (
Emergency Contact/Pick-Up
Carpool
Phone 1: (
)
Phone 2: (
)
Does this contact live on island?
Yes
No
Yes
No
Yes
No
Yes
No
Consent for Emergency Medical or Surgical Care
In the event that child becomes ill or is injured at school, and I cannot be contacted, school authorities have my permission to contact and
release my child to the custody of the emergency contacts listed above.
In the event that I cannot be contacted, I hereby give my permission and authorize Navy Hale Keiki School to obtain appropriate medical
or hospital personnel to provide emergency medical or surgical care for my child. I will assume the cost of any necessary medical or
surgical care.
Unless sooner revoked or terminated by me, this Consent for Emergency Medical or Surgical Care shall become null and void from and
after July 31, 2016.
I understand my obligation to submit in writing to the school office any changes in my contact information.
Signature of Parent/Legal Guardian
Date
2
HEALTH/MEDICAL INFORMATION
My child receives care for the following medical conditions or allergies:
No medical condition or allergies (Please skip to the next section.)
Yes, my child has the following medical condition(s). (Please check all that apply.):
Asthma
Behavioral Problems
Cancer/Leukemia
Chronic Cough/Wheezing
Diabetes
Hearing Problem
Heart Problems
Hemophilia
Hypertension
JRA Arthritis
Rheumatic Heart
Skin Problems
Sickle Cell Anemia
Vision Problems
Allergies:
Bee Sting
Medications
Food (Please specify):
Date and type of last reaction:
Other health concerns:
Category
of medical
Studentcondition
(Optional.orUsed
for are
record
keeping
purposes
to maintain
nonprofit
IfEthnic
symptoms
of this
allergy
exhibited
during
school,
I would like
the staffstatus.):
to take the following action(s):
My child takes the following medications: (Please annotate if these medications are take at home or school):
Verification of any allergies or medical conditions is required from your child's physician.
Students with severe allergies or those that take medication at school must have a Form SH36 on file.
FALL ENROLLMENT
Preschool through fourth grade classes are five-day-a-week programs ONLY. Regular attendance is expected.
School begins at 8 am. Students may be dropped off beginning at 7:30 am.
Regular School Hours
Early Bird Care (Care provided from 6 am to 7:30 am.)
Before School Care (Care provided from 7 am to 7:30 am.)
Full Time After School Care (Care provided Monday through Friday from dismissal to 5:30 pm.)
Standing Reservation After School Care (Care provided for up to three days a week from dismissal from 5:30 pm. Please
indicate days that you need care.)
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
Casual After School Care (Care can be scheduled ahead of time by calling for availability.)
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FRIDAY
FORMS
All forms must be thoroughly read, understood, agreed to, and signed by the student's parent or legal guardian before the student
may be accepted to Navy Hale Keiki School.
FINANCIAL AID APPLICATIONS/INFORMATION
Financial aid requests are managed separately from the admissions process. For full information, visit www.ohana.nhks.org. To assist us
in managing these two processes, please indicate if you plan to apply for Financial Aid:
Yes
No
BATHROOM READINESS/TOILET TRAINING
Prior to acceptance into the school, each student must be able to take care of his or her toilet functions without the assistance of any
other person. By signing below, I acknowledge that my child is able to take care of his or her toilet functions without the assitance of
others.
Signature of Parent/Guardian
Date
LIST IN SCHOOL DIRECTORY
Yes, I would like my address and phone number listed in the school directory for distribution to the school community
only.
No,
I do not want to be listed in the school directory.
Signature of Parent/Guardian
Date
2015-2016 PARENT HANDBOOK
My signature below affirms that I have received a parent handbook and that I am required to read and understand the contents of
I/We
accepthandbook.
all the proposed
and understand
that
violations
of any
codeof
ofany
conduct
or code
school
the parent
I acceptexpectations
all the proposed
expectations
and
understand
thatpolicy,
violations
policy,
ofprocedure
conduct orby myself or
school procedure by myself or my child may result in disciplinary action and disenrollment from Navy Hale Keiki School.
Signature of Parent/Guardian
Date
NEW STUDENTS ONLY
NEW STUDENT SCREENING
Preschool through kindergarten students must attend a social and emotional readiness screening on March 28, 2015 from 8:30 to 9:30 am.
Parents will attend an orientation session while children are screened in a separate location. Kindergarten students must also schedule
an academic readiness screening with the school's Curriculum/Student Support Specialist.
New students entering grades 1-4 will attend a full day of school prior to May 27, 2015 to assess the student's social, emotional and
academic readiness.
New students may be required to attend summer school prior to the start of school in August 2015.
Signature of Parent/Guardian
Date
NEW STUDENT RECORDS REQUEST
Only for students who have attended previous schools.
I hereby authorize Navy Hale Keiki School to obtain my child's previous school records to include progress reports, standardized test
scores, etc.
Name of School:
Address:
Street
City
Signature of Parent/Guardian
State
Zip
Date
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NAVY HALE KEIKI SCHOOL
PHOTOGRAPHIC AND PUBLICITY PERMISSION FORM
PRINTED PUBLICATIONS
Navy Hale Keiki School on occasion may wish to include captured imagery in printed publications. Images may be captured during
events organized and hosted by the school using film photography, digital photography, video, or other medium and maybe used in
the following publications. Examples of printed publications:
•
Navy Hale Keiki School bulletin
•
Navy Hale Keiki School leaflets and posters
•
Navy Hale Keiki School course brochures
•
Other Navy Hale Keiki School publicity material
•
Articles in local media, e.g. Star Bulletin, Navy News, Honolulu Magazine
•
Navy Hale Keiki School yearbook
Please note that any printed publications and publicity material may be replicated on the school website.
ONLINE AND ELECTRONIC PUBLICATIONS
Navy Hale Keiki School on occasion may wish to include captured imagery online and in electronic publications and on the school
website. Images may be captured during events organized and hosted by the school using film photography, digital photography,
video, or other medium and maybe used in the following publications. Examples of electronic publications:
•
Navy Hale Keiki School PowerPoint presentations
•
Navy Hale Keiki School prospectus
•
Navy Hale Keiki School course brochures
•
Navy Hale Keiki School website
Any images used for generic/illustrative purposes on the website may be replaced with more recent images/film regularly. Images of
students associated with particular news stories or events may remain on the school website in perpetuity, but will be archived as
new stories and events are added. Please note that websites can be viewed throughout the world and not just in the United States
where U.S. law applies.
CONDITIONS OF USE
1. We will not include personal email or postal addresses, or telephone or fax numbers on video, on our website or in any school
documentation.
2. We may use group or class photographs or footage with very general labels such as "science lesson" or "students at play."
PLEASE COMPLETE AND RETURN THIS FORM TO THE SCHOOL
This form gives consent for the school to use pictures of the person named below for media, general publicity, including (but not
limited to) the school website, leaflets, posters, display materials, prospectus, and reports.
Print Name: ________________________ Signed: ____________________________________________
Relationship to Child: ______________________________________
Date: ___________________
Print Child's Full Name: __________________________________________________________________
Please Select One of the Following:
____ YES, I give permission for my child to be included in any publicity/publication material, in school and externally, with local
media such as those mentioned in this form. I also give permission for any digital photography/video to be used for this use or for
press releases.
____ NO, I do not wish my child to be included in any publications and/or publicity materials either in school or externally with local
media such as those mentioned in this form. I also do not wish any digital photography/video to be used or for this use or press
release.
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NAVY HALE KEIKI SCHOOL
STUDENT INFORMATION FORM (Teacher Copy Page 1)
Student Name:
2015-2016 School Year
Student's Nickname(s):
Father's/Guardian's Name:
Occupation:
Mother's/Guardian's Name:
Occupation:
Siblings Names and Ages:
Ethnic Category of Student (Optional. Used for record
to maintain nonprofit status.):
Name
Agekeeping purposes
Name
Age
African American
Name
Age
1) Birth: Check One
Full Term
Name
Premature
Age
Primary language spoken at home:
Did your child need special care/extra hospitalization after birth? Please explain:
2) Age when child: (PS, PK, K students only)
3) Has your child attended school or day care?
Walked:
Said Single Words:
Yes
No
If yes, please list name and address of previous schools/programs attended:
4) Testing or services your child is currently receiving or has received in the past:
Infant Development Program
Operation Search
IEP
School
Speech
Other (please explain)
5) What are your child's strengths?
6) The following are happening at home and may be affecting my child's development and behavior:
Parental conflict, separation, divorce
Death in the family, major illness, or problem with a loved one
Change in the child's environment, e.g. recently moved, new family member, change in schedule or routine
Spouse attached to active deploying unit
Estimated Date of Deployment
Anticipated Length of Deployment
Other (please explain):
7) Please provide any additional information which you feel may help your child's teacher to better understand your
child's social emotional, physical, cognitive, language, academic, and behavioral needs.
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NAVY HALE KEIKI SCHOOL
STUDENT INFORMATION FORM (Teacher Copy Page 2)
Please review the list below. Check concerns that you feel apply to your child and check the details that apply.
SOCIALIZATION:
Very shy
Tantrums
BEHAVIOR:
Lacks confidence
Does not follow rules
ATTENTION SPAN:
Does not finish task
ACTIVITY LEVEL:
Squirmy, fidgety, restless
Hard to handle behavior
Overly active
Squints or frowns to see
Needs to have things repeated
Wants TV on loudly
Speaks loudly
Hard to understand
Difficulty expressing him/herself
Difficulty following or remembering directions or routine
Clumsy
BODY CONTROL/MOVEMENT:
Holds things too close or too far to see
Seems inattentive to directions
Needs to watch your face when you talk
Mispronounces many words
LANGUAGE/UNDERSTANDING:
Does not interact well with other children
Goes from one activity to another without really "getting into it"
VISION:
HEARING:
Separation Anxiety
Tilts head to listen
Mispronounces many words
Stutters/voice sounds unusual
Doesn't remember information from day to day
Doesn't "pick up" new words or ideas easily
Difficulty with throwing or catching a ball, with jumping or hopping
Difficulty using scissors, pencils, or building
Difficulty using two hands together
Additional Comments/Information (Optional):
Your hopes and fears for your child (Required):
I understand the information I provide is to be used by the teaching and administrative staff of Navy Hale Keiki School to aid in
providing an effective educational program for my child. I hereby agree to any diagnostic screening and/or testing the school
feels necessary to administer. The school will notify me if such screening/testing is deemed necessary and will make the
results/recommendations available for my review and for further consideration.
The information provided is true with no omissions. I understand that failure to disclose information could be the basis for
involuntary disenrollment and forfeiture of any fees paid to date of withdrawal.
Parent/Guardian Signature
Date
Relationship to Student
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NAVY HALE KEIKI SCHOOL
SCHOOL YEAR 2015-2016 FALL TUITION SCHEDULE
MONTHLY BILLING STATEMENTS ARE NOT PROVIDED
Please refer to this sheet for any questions regarding billing and procedures.
Tuition and fees will be deducted from the parent designated bank account on the 15th of each month starting July 15, 2015.
Payments not available for deduction on the 15th will be assessed a $30.00 late fee.
Tuition payments begin July 15, 2015 and end on April 15, 2016.
NO REGULAR SCHOOL YEAR TUITION PAYMENT WILL BE DUE FOR THE MONTH OF MAY 2015 FOR ACCOUNTS IN GOOD STANDING.
The $200.00 tuition deposit will be applied to your first tuition payment deducted on July 15, 2015.
GRADE
Preschool
(8:00 a.m. - 11:30 a.m.)
Prekindergarten
(8:00 a.m. - 11:45 a.m.)
Kindergarten
(8:00 a.m. - 2:30 p.m.)*
1st Grade
(8:00 a.m. - 2:45 p.m.)*
2nd - 4th Grades
(8:00 a.m. - 3:00 p.m.)*
REGISTRATION
FEE
TUITION
DEPOSIT
ANNUAL TUITION
10 MONTHLY INSTALLMENTS
(BEGINS JULY 15th & ENDS APRIL 15th)
$175.00
$200.00
$6,340.00
$634.00
$175.00
$200.00
$6,340.00
$634.00
$175.00
$200.00
$8,080.00
$808.00
$175.00
$200.00
$8,230.00
$823.00
$175.00
$200.00
$8,380.00
$838.00
*Wednesday is an early dismissal day.
Wednesday dismissal times are as follows: Kindergarten: 12:00 pm, 1st: 12:15 pm, 2nd - 4th: 12:30 pm
BEFORE & AFTER SCHOOL CARE SERVICES
Monthly Before & After School program fees are prorated in the months of October, December & March due to the extended time off school.
Early Bird Care (EBC), Before School Care (BSC) and Full Time After School Care are deducted in the month care is incurred.
Payments for After School Care Standing Reservations and Casual Care will be deducted with the following month's tuition payment.
STANDING RESERVATION OR CASUAL CARE IS NOT AVAILABLE FOR EBC/BSC.
SPACE IN EARLY BIRD CARE AND BEFORE SCHOOL CARE IS VERY LIMITED. BE SURE TO RESERVE YOUR CHILD'S SPACE WELL AHEAD OF TIME.
PLEASE MAKE YOUR RESERVATIONS FOR CASUAL CARE AT LEAST 3 DAYS IN ADVANCE.
GRADE
Preschool
Prekindergarten
Kindergarten
1st-4th Grades
MONTHLY
EARLY BIRD CARE
MONTHLY
BEFORE SCHOOL
CARE
MONTHLY
AFTER SCHOOL
CARE
DAILY CASUAL AFTER SCHOOL
CARE/STANDING RESERVATION
6:00 a.m. - 7:30 a.m.
7:00 a.m. - 7:30 a.m.
until 5:30 p.m.
until 5:30 p.m.
$154.00
$154.00
$154.00
$154.00
$65.00
$65.00
$65.00
$65.00
$304.00
$304.00
$214.00
$202.00
$16.75
$16.75
$11.75
$11.00
If the reservation is no longer needed, care must be cancelled no later than 7:30 a.m. on that day.
A late charge of $10.00 for every 10 minutes or fraction thereof will be assessed when children are not picked up by 5:30 p.m.
when child/ren are not picked up by 5:30 p.m.
8
NAVY HALE KEIKI SCHOOL
MILITARY TUITION AGREEMENT – SCHOOL YEAR 2015-2016
Please read prior to registration. Signatures and initials from both guardians are required (if applicable). At least one guardian must
complete his/her signature and initials at registration and be witnessed by the ADMINISTRATIVE STAFF.
For Military Families Only: If you are not the active duty military member and you are signing in their place, a copy of your Power of
Attorney will be required.
1. _____ Registration Fees and Tuition Deposits are due at the time of registration and are not refundable or transferable.
2. _____ The Annual Tuition is payable in full at the beginning of the school year. For the convenience of parents, an agreement
between FACTS Tuition Management Company and each family is required. Tuition payments will be deducted from the
th
parent designated bank account on the 15 of each month starting July 15, 2015. The subsequent nine tuition installments
will be deducted each month. Students enrolling after the start of the school year may also take advantage of the installment
plan. The installment amount will be the same as those for other students; however, the amount collected upon enrollment
will also include a prorated portion of the first installment.
th
3. _____ Navy Hale Keiki School does not generate billing statements. Payments not available for deduction by the 15 of each
th
month will incur a penalty fee of $30.00 per student. A second attempt to collect funds will occur on the 30 of the month.
The family account will be transferred to the school if funds are not available on the second attempt and will incur an additional
charge of 10% of the delinquent amount. Accounts in arrears over 30 days will be reported to the Board of Governors and may
result in disenrollment from school. All expenses incurred by the school resulting from the collection of a delinquent account
will be charged to the family necessitating such expense.
4. _____ Three weeks (3) advance written notice to the Business Office is required prior to withdrawal of a student from school. In
addition, the parent or guardian agrees to pay a disenrollment fee of $1,000.00 per student, or the remaining unpaid amount of
the annual tuition, whichever is less, if the student is disenrolled for any reason other than moving off O’ahu. Notification must
be provided, in writing, to the NHKS office no later than June 1, 2015. Notification after June 1, 2015, will result in the
assessment of the $1,000.00 disenrollment fee. A copy of official military orders or Bill of Lading from the moving company
along with the school’s disenrollment notice must be submitted to waive the disenrollment fee. The disenrollment fee is
applicable at the time of signing for those students being registered after June 1, 2015.
5. _____ Tuition refunds are not given for students involuntarily withdrawn from school due to uncorrected behavior.
6. _____ Tuition refunds and disenrollment fee waivers are not given for students voluntarily withdrawn from school for reasons
including, but not limited to, moving homes on O’ahu, receiving a geographical exemption for another school, vacations, or
deployments.
7. _____ Children should be picked up promptly at dismissal times. A late pick up fee of $2.00 for every 5 minutes or fraction
th
thereof will be assessed. After the 5 late pick-up, parents will be charged $10.00 for every 5 minutes or fraction thereof (Refer
to the Parent Handbook for additional information on late pick-up charges.)
8. _____ Children in After School Care who are not picked up by 5:30 p.m. will be charged $10.00 for every 10 minutes or fraction
thereof after 5:30 p.m. (Refer to the Parent Handbook for additional information on After School Care dismissal policies.)
I have read, understand, and agree to the above. In the event that my account is 60 days or more in arrears, and following
unsuccessful attempts by Navy Hale Keiki School to communicate with and/or collect from me, I consent to Navy Hale Keiki School
communicating with my Commanding Officer, Officer-In-Charge, or other employer, however denoted, concerning my
indebtedness/delinquent account. If legal action is necessitated, I agree to pay any additional legal or collection costs. If my
account is sent to collections, I agree that my account will be assessed an additional 50% of the outstanding balance. All above
statements, #1-8, become applicable at the time of signing.
Student’s Legal Name (please print) _______________________________________________
______________________________________
Parent Name (Print)
____________________________________
Parent Name (Print)
______________________________________
Parent Social Security Number
____________________________________
Parent Social Security Number
______________________________________
Parent Name (Signature)
____________________________________
Parent Name (Signature)
Date: ________________
Business Manager’s Signature: ______________________________
Date: __________________
9
NAVY HALE KEIKI SCHOOL
2015 - 2016 PARENT MARKETING SURVEY
Navy Hale Keiki School (NHKS) is conducting a marketing survey. Our survey serves two purposes for gathering information. First,
we would like to know how you initially became aware of NHKS. Then, we would like to know what influenced your final decision to
enroll your child(ren). Thank you for taking the time to participate in our survey.
INITIAL INTEREST
Please circle ALL that apply.
NHKS sign in front
of the school
Visit to NHKS
NHKS Website
Hawaii Association of Independent
Schools (HAIS) Website
Welcome Aboard Packet
(received when PCSing to
Hawaii)
Navy Family
Service Center
Army Community
Service Center
Hickam Family Support Center
Recommendations from parents
on the Mainland/Other
Recommendations from
parents in Hawaii
Other:
Comments: ________________________________________________________________________________________
FINAL DECISION
Please circle ALL that apply.
NHKS Sign in front
of the school
Visit to NHKS
NHKS Website
Hawaii Association of Independent
Schools (HAIS) Website
Welcome Aboard Packet
(received when PCSing to
Hawaii)
Navy Family
Service Center
Army Community
Service Center
Hickam Family Support Center
Recommendations from parents
on the Mainland/Other
Recommendations from
parents in Hawaii
Other:
Comments: _______________________________________________________________________________
Student Name: ___________________________________
Grade: __________________
2015-2016
The school would like extended family to feel a part of our 'Ohana (family) through annual report mailings and as a part of our
Annual Appeal. Please complete information for grandparents or other friends/family members to be included in our database.
Name: _______________________________________
Name: ________________________________________
Address: _______________________________________
Address: ________________________________________
_______________________________________
________________________________________
Name: _______________________________________
Name: ________________________________________
Address: _______________________________________
Address: ________________________________________
________________________________________
_______________________________________
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