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Ka Honua Momona Waiver & Intake Sheet 2019

In consideration of being allowed to participate in any way in Ka Honua Momona International's Projects or Programs for the year 2019, its related events and activities I, the undersigned, acknowledge, appreciate, and agree that while participating in Ka Honua Momona activities:

1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation and,

3. I willingly agree to comply with the stated and customary terms and conditions for use of the rented equipment while participating. If however, I observe any unusual significant hazard during my presence or participation, I will bring such to the attention of the nearest official immediately,

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE,INDEMNIFY, AND HOLD HARMLESS KHM INTERNATIONAL , their officers, officials, agents and/or employees,Department of Hawaiian Home Lands, owners and lessors of premises used for the activity ("Releasees"), WITHRESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH , or loss or damage to person or property,WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE , to the fullest extent of law.

5. I am responsible for returning everything back in the condition it was rented/lent to me. If something is lost, stolen or broken, then I am responsible and will be charged for it.

6. Participants may be photographed and/or videotaped during workshops, and KHM International reserves the right to use these photographs and video in its publications, website and other materials.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT AND FULLY UNDERSTAND ITS TERMS, AND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND DO SO FREELY AND VOLUNTARILY WITHOUT INDUCEMENT.

I Agree

April 25, 2024

First Volunteer/Visitor Name

First Name*

Last Name*

Phone*
First Volunteer/Visitor Date of Birth*
First Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
First Volunteer/Visitor Signature*
Second Volunteer/Visitor Name

First Name*

Last Name*
Second Volunteer/Visitor Date of Birth*
Second Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Third Volunteer/Visitor Name

First Name*

Last Name*
Third Volunteer/Visitor Date of Birth*
Third Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Fourth Volunteer/Visitor Name

First Name*

Last Name*
Fourth Volunteer/Visitor Date of Birth*
Fourth Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Fifth Volunteer/Visitor Name

First Name*

Last Name*
Fifth Volunteer/Visitor Date of Birth*
Fifth Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Sixth Volunteer/Visitor Name

First Name*

Last Name*
Sixth Volunteer/Visitor Date of Birth*
Sixth Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Seventh Volunteer/Visitor Name

First Name*

Last Name*
Seventh Volunteer/Visitor Date of Birth*
Seventh Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Eighth Volunteer/Visitor Name

First Name*

Last Name*
Eighth Volunteer/Visitor Date of Birth*
Eighth Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Ninth Volunteer/Visitor Name

First Name*

Last Name*
Ninth Volunteer/Visitor Date of Birth*
Ninth Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Tenth Volunteer/Visitor Name

First Name*

Last Name*
Tenth Volunteer/Visitor Date of Birth*
Tenth Volunteer/Visitor Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Volunteer/Visitor Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
I would like to receive newsletters, workday ads, updates from KHM
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Purpose of visit?*
Site Visit
Volunteer work
Extended Classroom
Use of KHM site & facilities
Program
Other

Other:

School/group/organization you are affiliated with: *
Hawaiian Ancestry?*
Yes
No

List any medical condition/dietary restrictions you may have *
(Minors PreK-12 grade) Eliglible for Free/Reduced Lunch?*
Yes
No
N/A
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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