Pāia Youth & Cultural Center

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PYCC Membership Form July 1, 2026 - July 1, 2027

Dear Parent or Guardian:

Your child has expressed an interest in becoming a member of the Pā‘ia Youth & Cultural Center.

Our membership is FREE and open to youth ages 9-19 years old. Youth under 9 years old are allowed to join the skate park; but they must be always accompanied by an adult.

The PYCC has a variety of life skills programs and a drop-in center offering many fun and educational activities. We are located on the beach at Pā‘ia Bay.

Email *

Youth First Name *

Youth Last Name *

Gender *

Male

Female

Prefer not to say

Birthdate *

School *

Grade *

Parent / Guardian First Name *

Parent / Guardian Last Name *

Parent / Guardian Phone Number *

Emergency Contact Name * Please list a local contact other than the primary parent/guardian.

Emergency Contact Relationship * (e.g., Aunt, Grandparent, Family Friend)

Emergency Contact Phone Number *

Home Community * What town or area do you live in?

Pāʻia

Kūʻau

Spreckelsville

Haʻikū

Hāliʻimaile

Makawao

Pukalani

Kula

Kēōkea

ʻUlupalakua

Kahului

Wailuku

Waiheʻe

Waiehu

Waikapū

Māʻalaea

Kīhei

Wailea

Mākena

Lāhainā

Kāʻanapali

Nāpili

Kapalua

Hāna

Keʻanae

Other / Off-Island

Mailing Address

Address (or P.O. Box) *

Apartment, Suite, Unit, etc.

City *

State *

ZIP Code *

Allergies / Medical Conditions

* Please describe any known medical, allergic, or health concerns:

Ethnicity

African American

Native American

Asian

Pacific Islander

White

Portuguese

Filipino

Hawaiian

Hispanic/ Latino

Other

All optional information below is used only for reporting purposes only and are strictly confidential.

Household Size Number of people in household including youth

Annual Household Income

Justice System Involvement Has the Youth Member ever been involved in the criminal justice system?

Yes

Referral Source If you are a new member, How did you hear about PYCC?

School

Family

Radio

Event

Staff

Friend

Instagram

Facebook

PYCC Membership Form July 1, 2026 - July 1, 2027

Click Submit to finish.

This form was created by Pāia Youth Council Inc.

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