2024 Registration | Pacific Buddhist Academy

Please complete the following summer school registration form.

Student First Name*

Student Last Name*

Student Email

Student Grade Level for 2024-25 School Year

Current School

Parent 1 First Name (preferred contact)

Parent 1 Last Name

Parent 1 Relationship

Parent 1 Email

Parent 1 Phone - -

Parent 1 - Place of Employment

Parent 1 - Work Phone - -

Parent 2 First Name

Parent 2 Last Name

Parent 2 Relationship

Parent 2 Phone - -

Parent 2 Email

Parent 2 - Place of Employment

Parent 2 - Work Phone - -

Child lives with:

Address

Use Google Smart Search for Address

Address 1:

City:

Country:

State/Province:

Postal Code:

Zip Code

Please provide 2 emergency contacts that are NOT listed as the parent 1 or parent 2.

Emergency Contact Name (Preferred Contact)

Please provide a contact not listed as Parent 1 or Parent 2

Relationship to Child

Please provide a contact not listed as Parent 1 or Parent 2

Phone Number - -

Please provide a contact not listed as Parent 1 or Parent 2

Phone Number - Work/Home - -

Please provide a contact not listed as Parent 1 or Parent 2

Emergency Contact Name - 2

Please provide a contact not listed as Parent 1 or Parent 2

Relationship to Child

Please provide a contact not listed as Parent 1 or Parent 2

Phone Number - -

Please provide a contact not listed as Parent 1 or Parent 2

Emergency Contact Name 3

Please provide a contact not listed as Parent 1 or Parent 2

Relationship to Child

Please provide a contact not listed as Parent 1 or Parent 2

Phone Number - -

Please provide a contact not listed as Parent 1 or Parent 2

Please complete the following health history form.

New families must provide documentation of current immunizations along with completion of health history forms.

Student Full Name

Student Birthdate

Student Gender

Student Allergies

If yes to any of the above allergies, please explain

Severity of Allergic Reaction

Vision

Hearing

Asthma

Heart Problems

My child takes prescription medication daily

Medication Name & Dosage

Explanation for any checked items listed above

Please upload Health Immunization Record (new families only)

(doc, jpeg, jpg, pdf, png)

All school personnel will administer only First Aid and Emergency CPR. In the case of an emergency, the child will be taken via ambulance to Kapiolani Medical Center for Women & Children Emergency Room (or the closest medical facility).

Please note: Health Insurance is a requirement for enrollment at PBA summer school.

Insurance Company Name

Policy #

Group #

Subscriber Name

Electronic signature acknowledges parent/guardian provides the above medical information freely and agrees to the emergency procedure above. Permission is hereby granted, if circumstances require, for the emergency department or family physician to provide initial examination, treatment and contact of the family for consultation.

Parent/Guardian Electronic Signature

Please enter parent/guardian first and last name. We acknowledge that Pacific Buddhist Academy reserves the right to deny participation in any school activity.

Please read and sign the following general release waivers.

Your son/daughter/ward is eligible to participate in school sponsored activities that help to develop them academically, physically, socially, and spiritually. These include but are not limited to: field trips or activities organized by individual classroom teachers and/or program coordinators. These activities will take place under the guidance and supervision of employees from PBA (classroom teachers and/or program coordinators). Trips are taken on the PBA school bus driven by a certified driver.

I have read and acknowledge the policies listed above.

Please enter parent/guardian first and last name. We acknowledge that Pacific Buddhist Academy reserves the right to deny participation in any school activity.

My child has my permission to travel by school authorized transportation on any school sponsored activity while enrolled at Pacific Buddhist Academy. Traveling away from school may involve risks. PBA will take every precaution necessary to ensure the safety and welfare of my child. We agree to release, indemnify, and hold harmless Pacific Buddhist Academy, its employees, agents, and representatives and chaperons from all liabilities and claims for any injuries, losses, death, damages, or cost (including reasonable attorney’s fees) which arise out of or incident to our child’s attendance, or participation in any school related or school approved trip, excursion, or activity.

We acknowledge that we have read this agreement and fully understand its content. I also understand that if the trip leader determines that my son/daughter/ward has broken the rules of behavior and safety that he/she will be sent home and I will pick up my child and I will assume responsibility for all costs incurred.

I have read and understand the policies listed above

Please enter parent/guardian first and last name. We acknowledge that Pacific Buddhist Academy reserves the right to deny participation in any school activity.

I understand that from time to time, PBA is featured in a newspaper, television spot, magazine, or other media. At such times, photo or videos of the student may be taken to enhance the feature. In addition, the student’s name may also be used to identify the person in the photo. No remuneration or compensation is given in exchange for the use of such photos or videos. (The photo waiver/release covers any such situation during Pacific Buddhist Academy's 2023 Summer School Program. If no mark notated, permission is assumed.)

Please select an option below regarding photo release / waiver.

Statement of non-discrimination

Pacific Buddhist Academy does not discriminate on the basis of sex, religion, race, color, national and ethnic origin, or sexual orientation in the administration of its educational policies, admissions policies, and other school-administered programs.

Summative acknowledgement and waiver

The undersigned hereby agree to release and to hold harmless PBA, its agents, and employees of any the foregoing from all claims, damages and/or other liabilities for injuries which may occur to the student named above and any property damage which are not the result of gross negligence by PBA, its agents, or employees. The undersigned also agree to indemnify PBA for any and all damages that may be caused by the student named above and also agree to accept the rules and regulations of PBA as stated in the current catalog and handbook. The undersigned also agree that PBA may suspend or terminate any student at PBA’s sole discretion should it become necessary.

I have read and acknowledge the policies listed above.

Please choose the options below for Session 1: June 3, 2024 – June 21, 2023 (Holiday: June 11, 2024 and June 19, 2024)

Period 1 Selection

Period 2 Selection

Period 3 Selection

Please choose options below for Session 2: June 24, 2024 – July 12, 2024 (Holiday: July 4, 2024)

Period 1 Selection

Period 2 Selection

Period 3 Selection

Total Amount$0.00

Payment Method:*

Payment Notes/Additional Info:

Name on Card:*

Email You Want Associated with Credit Card Payment:*

Credit or debit card*