Keiki O Ka Aina Family Programs - LOKAHI Giving Project, Parent Participation, HIPPY, Parents As Teachers, Supporting Families Affected by Incarceration, AIM

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Preschool

LOKAHI

KOKA Online Intake/Recruitment Form

Please use this online intake/recruitment form to provide information about your keiki and the programs you would like to enroll in. This form is primarily used to gather information for the intinal first step in enrolling in our programs.

You will be contacted by a program lead or our registration office with details about the next step in our registration process.

All of your information is held private and will only be used for enrolling into Keiki O Ka`Aina programs

Parent or Caregiver Information
First Name	Last Name
Relationship to Child
Mailing Address	City	Zip
Email address
Home Phone	Work Phone
Other Phone	Best Time to Call

First Child's Information

First Name

Last Name

Sex

DOB - mm/dd/yy

Age

Program

Is This Child Hawaiian or Part Hawaiian

Yes No

Has Your Child ever attended a formal drop off preschool / daycare

Yes No

If Yes to Preschool / Daycare - please specify where

Second Child's Information

First Name

Last Name

Sex

DOB - mm/dd/yy

Age

Program

Is This Child Hawaiian or Part Hawaiian

Yes No

Has Your Child ever attended a formal drop off preschool / daycare

Yes No

If Yes to Preschool / Daycare - please specify where

Third Child's Information

First Name

Last Name

Sex

DOB - mm/dd/yy

Age

Program

Is This Child Hawaiian or Part Hawaiian

Yes No

Has Your Child ever attended a formal drop off preschool / daycare

Yes No

If Yes to Preschool / Daycare - please specify where

Which Program(s) are you interested in Please select location interested in
Kulia I Ka Nu`u
HIPPY - Home Instruction for Parents of Preschool Youngsters
PAT - Parents As Teachers
SFAI - Supporting Families Affected by Incarceration
Healthy Marriages - Wednesday Evenings	Yes
KOKA Preschool	Yes
Poli's Place
PPP- Parent Participation Preschools
HELP- Childcare	Yes
Other
Questions for Poli's Place Only
Do you feel your keiki has special needs?	Yes No
If yes, please specify
Has your keiki been medically diagnosed with special needs?	Yes No
If yes, please specify

How did you find out about our programs
Other
Comments / Questions

Keiki O Ka ' Āina Family Learning Centers
3097 Kalihi Street Honolulu, HI 96819
808-843-2502
keikiokaaina.org

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