Kaneohe Application

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Please fill out the following application. You will hear back from the Kaneohe Center Director.

    Child's Name

    Date of Birth

    Home Address

    Mailing Address

    Home Phone

    Email

    Mother's Name

    Date of Birth

    Employer Name

    Occupation

    Business Phone

    Cell Phone

    Father's Name

    Date of Birth

    Employer Name

    Occupation

    Business Phone

    Cell Phone

    Child's Physician

    Physician's Phone Number

    Medical Insurance Carrier

    Policy Number

    Allergies

    Tuition payment will be made by
    ParentArborOpen DoorsFirst-to-WorkPauahi Keiki ScholarsKeiki O Ka AirnaFederal

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