HAKA DARE Database

Disaster AnD Rescue EVACUATION

Please complete the form as if there is a current emergency
Full Name*

First NameLast Name
Mobile Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
E-mail*
Residential Address (if no house number, provide directions below)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Directions to your property from a major roadway.*
Please be as detailed as possible.
Do you own or rent?*

OwnRentOther
Does the property have a fence and gate?*

YesNo
Do you have pets, service animal, or livestock?

YesNo

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, or your animals?*

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

YesNoMaybe
How many people live in the home currently including yourself?
Do you work with or receive services from a State, County, or nonprofit Agency? Example: DHS, Hope Services, DDD, Office of Aging, etc.
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
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Disaster AnD Rescue EVACUATION