First Name *

Last Name *

Email *

Phone *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Residency Information *

Address

Street Address *

City *

State *

Country *

Postal code *

GROUP NAME: What is the name of your group (school, club, ʻohana, etc.)? *

Indicate self if: a) not with a group; b) course or workshop attendance; or c) community feed or donation.

What date will you be participating? *

List date range or multiple dates (if applicable)

Pōhāhā I Ka Lani program *

Pōhāhā I Ka Lani Course/Workshop Name (If applicable)

This is for courses or workshops provided by Pōhāhā I Ka Lani. Leave blank if not applicable.

Have you participated with Pōhāhā I Ka Lani before? *

Yes

Media Release

I hereby grant Pōhāhā I Ka Lani and its partners permission to use photos and/or video of me, including my image, likeness, and voice. I understand that Pōhāhā I Ka Lani may publish the material I approve in any manner the organization deems appropriate in order to document or promote the work of Pōhāhā I Ka Lani and its partners. This includes brochures, websites, email messages, social media, educational materials, and any other publication whether printed or electronic.

Select one *

Yes

If "No", you must:

a) submit a picture below

b) come to see us during participation so we can take a photo of you

This is so we may identify you in the pictures to modify your face and likeness prior to our use.

Self-Portrait Image Upload (If you selected "No")

Liability Waiver & Release of Indemnity

We (I) the undersigned, my heirs, executors, and administrators hereby accept full responsibility for my participation, injury or other liability in connection with Pōhāhā I Ka Lani programs and sites and any other location, programs activities under the exclusive control of Pōhāhā I Ka Lani by said individual(s), authorized accompanying person(s), and their related organization and agree to indemnify and release and discharge Pōhāhā I Ka Lani, employees, agents, assigns, leaseholders, landowners, and grantors from any and all claims or actions for property damage, personal injury, and/or death arising from activities under the exclusive control of Pōhāhā I Ka Lani.

Signature (Liability Waiver & Release of Indemnity) *

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