Na Kama Pono Application Form

Date of Application: _______________________    Date of  Receipt:_______________________________

Name of Child:_________________________________________________________________________

Gender :  Boy  / Girl                                                   Birthdate:_____________________________________

Parent (s) Name:________________________________________________________________________

Phone Nos: ______________________/________________________/_____________________________

                                    (home)                                   (cell)                                  (work)

Mailing Address: ________________________________________________________________________

Payee's Social Security No.:  _______________________________________________________________

Date of  intended enrollment: _______________________________________________________________

Parent Status: Check one:

_______Part time student  (____ credits: _____________________________________program)

_______Full time student

_______Part time Faculty/staff

_______Full time Faculty/staff

Priority Status:

_______Have been awarded Financial Aid from  KCC

_______Single (Includes: Divorced or Widowed)

_______Separated from Spouse

****Child must be potty-trained and at least 2 years 9 months by the time of enrollment****