HAKA DARE Database

Do you or someone in your household have a service animal?

YesNo
Do you or someone in your household have an Emotional Support Animal (ESA)?

YesNo
Do you or anyone in your household have a disability? If yes, please explain.
Do you or anyone in your household take medication prescribed by a physician?

YesNo
Which pharmacy do you use?
Ex: Safeway, CVS Pahoa, KTA, etc.

In the event of an emergency, do you give HAKA and its associates permission to enter the property to assist you with relocating yourself, your family, and your animals?*

YesNo
Any additional notes or instructions:
Do you need housing for yourself and family members?*

YesNoMaybe
How many people live in the home currently including yourself?
Emergency Contact: (someone other than yourself)*

First NameLast Name
Emergency Contact's Phone Number:*

Area CodePhone Number
Are you Hawaiian or Part-Hawaiian? (For statistics only)*

YesNo
I understand that HAKA is a registered nonprofit organization. Participant acknowledges and agrees that it may be necessary for some of the Participant's personal identifiable information to be provided to certain representatives of the nonprofit, third party administrators and partners during an emergency. By signing, the Participant acknowledges having been informed of the possible transfer and sharing of information.
Signature

Clear
Should be Empty:

Disaster Animal Rescue Enrollment