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Keiki Impacted by Wildfires 24-25
Aloha, thank you for taking the time to fill out this registration form. Some examples of services/support we are providing are: immediate needs, basic needs, assistance with acquiring important documents that were lost in the disaster, food, educational planning and tutoring for keiki, extra-curricular classes in art, culture, and fishing, and monthly 'ohana fun days. We are also helping with keiki aftercare which could be many things depending on what your keiki needs.
Contact Information
Child's Name
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First Name
Last Name
Child/Client's birthdate
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(mm/%d/yyyy)
Child's Phone Number
School
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Grade
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Parent/ Guardian's Name
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First Name
Last Name
Parent/Guardian's Email
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Verify Email
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Parent/Guardian's Phone Number
*
Current Mailing Address
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Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Previous Address
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Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Physical Address
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Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Emergency Contact's Name
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First Name
Last Name
Emergency Contact's Phone Number
*
Background information
Child Gender at Birth
*
Female
Male
Gender Identity
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Maui Hui Malama is grant funded and requires us to ask this question.
Female
Male
Gender Diverse
Mahuwahine/Mahukane
Other
Sexual Orientation
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Maui Hui Malama is grant funded and requires us to ask this question.
Straight
Lesbian
Gay
Bisexual
Other
Public Assistance - (Used for Country Grant Reporting)
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Maui Hui Malama is grant funded and requires us to ask this question. My keiki receives
Free/Reduced Lunch
SNAP/EBT
TANF
Med Quest
HUD
ALICE (Assets Limited, Income Constrained, Employed) You earn above the Federal Poverty Level (FPL) so you don't qualify for government assistance but you make less than what's needed to afford basic essentials. There is no room for emergency expenses.
None
Geographic Area
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Central Maui
East Maui
Lana`i
Moloka'i
Other
South Maui
Upcountry
West Maui
Ethnicity - (Used for State Grant Reporting)
*
Please select all that apply based on these options
American Indian
Black
Cambodian
Caucasian (Not Portuguese)
Chinese
Filipino
Hawaiian (Full, Part)
Japanese
Korean
Laotian
Marshallese
Micronesian
Mixed (Not Hawaiian)
Other
Other Asian
Other Pacific Islander
Portuguese
Puerto Rican, Hispanic
Samoan
Tongan
Unknown
Vietnamese
Ethnicity - (Used for County Grant Reporting)
*
Please select all that apply based on these options
African American
Asian (Chinese, Japanese, Filipino, etc.)
Caucasian
Hawaiian / Part Hawaiian
Hispanic (Guatemalan, Mexican, Puerto Rican, etc.)
Other
Pacific Islander (Marshallese, Samoan, etc.)
Does your child have any preferred pronouns?
How does your child qualify as a keiki impacted by the wildfires?
Please let us know how your keiki was impacted by the wildfires. In our intake we will ask for verification like mail with your name and address from wildfire-affected area, keiki report card from school, pay stub for parent who worked in wildfire-affected area, etc. All verification documents must show a date around August 8th, name of child or parent, and name of address/work/school, etc. from the wildfire affected area. If you need help with this question, please call Daisha at (808)830-6096 or email daisha@mauihui.org.
What is your child's barrier toward their educational, career, or cultural goals?
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What services are you hoping to get help with this year?
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How did you hear about us/this program?
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Does your child have any known allergies?
*
Agreements
Liability Release
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I hereby release, hold harmless, and indemnify Maui Hui Malama, its Board of Directors, employees and staff, from and against all claims, including but not limited to claims for property damage and/or personal injuries arising out of my child’s participation in MHM’s group, activities, or the rendering of any medical treatment. I understand that MHM will make reasonable attempts to notify me or the emergency contact as soon as possible in the event of illness or injury to my child to obtain authorization to administer necessary medical treatment. I further give consent to MHM to secure and authorize such medical treatment if MHM is unable to speak with me or the emergency contact for the above named child while under this supervision. I also agree to pay all costs and fees contingent upon receiving emergency medical care or treatment as secured or authorized under this content.
I agree
Liability Release Copy
*
I hereby release, hold harmless, and indemnify Maui Hui Malama, its Board of Directors, employees and staff, from and against all claims, including but not limited to claims for property damage and/or personal injuries arising out of my child’s participation in MHM’s group, activities, or the rendering of any medical treatment. I understand that MHM will make reasonable attempts to notify me or the emergency contact as soon as possible in the event of illness or injury to my child to obtain authorization to administer necessary medical treatment. I further give consent to MHM to secure and authorize such medical treatment if MHM is unable to speak with me or the emergency contact for the above named child while under this supervision. I also agree to pay all costs and fees contingent upon receiving emergency medical care or treatment as secured or authorized under this content.
I agree
Subsrcibe to Maui Hui Malama
By checking here I agree to receive emails, mail, and phone calls on information regarding this program as well as other information related to Department of Education, any school, and any educational entity and Maui Hui Malama
I agree
Legal Guardian
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I confirm I am the legal guardian of the participant listed above or 18 years or older.
I agree
Please type your full name in place of your signature.