Mālama Nā Keiki - Healthy Hāpai Community Baby Shower Registration

8th Annual
Mālama Nā Keiki
Healthy Hāpai Community
Baby Shower Registration

Aloha,

Hui Mālama Ola Nā ʻŌiwi will be hosting this year’s Mālama Nā Keiki event.

Please complete the form below to register.

We will also be asking for insurance information as part of registration. This is collected solely for federal reporting purposes and will not affect your participation in the event.

Mahalo for helping us create a fun, safe, and meaningful wellness experience for your ʻohana!

If you have any questions, please contact us at (808) 657-0017 or (808) 969-9220.

Mahalo,
Hui Mālama Ola Nā ʻŌiwi
Medical/Behavioral Health ServicesTraditional Hawaiian HealthExerciseNutritionDiabetes ProgramSpecialty TransportationHealthy Hāpai ProgramHypertensionCancer Support Group
CONTACT INFORMATION
Patient Full Name:*

First NameMiddle InitialLegal Last Name
Nickname
Suffix:
Residence Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing / Other Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Phone #:*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birthdate:*

MonthDayYear
Date
Age:
Social Security Number*
Name of Primary Care Provider:
YesNo
Who referred you?
SingleMarriedLegally SeparatedPartnerDivorcedWidowed
MaleFemaleTransgender Male/FemaleTransgender Female/MaleOtherChoose not to disclose
StraightGay/LesbianBisexualSomething elseDon't KnowChoose not to disclose
RESPONSIBLE PARTY INFORMATION
SelfSpouseParentGuardian
Name:

First NameLast Name
Contact Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Mailing address:

Street Address

Street Address Line 2

CityState

Zip Code
NoneMedical
Primary Insurance:
Membership ID#:
Group#:
Subscriber Name:
Date of Birth:

MonthDayYear
Date
SSN#:
NoneMedical
Secondary Insurance:
Membership ID#:
Group#:
Subscriber Name:
Date of Birth:

MonthDayYear
Date
SSN#:
I authorize this office to release to the named insurance company any information necessary to secure insurance payment. Ihereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of thissignature on all insurance submissions. I understand I am responsible for all charges regardless of insurance coverage.*
Type your initials to authorize.
YesNo
YesNo
YesNo
YesNoI don't know
DiabetesHypertensionCancer
HOUSEHOLD INFORMATION
YesNo
Income:*
MonthlyAnnual
Family Size:*
Not HomelessHomeless ShelterTransitionalDoubling UpStreetYes, but unknownOther
If homeless, for how long?:
If Other, enter details below:
EnglishHawaiianOther
If you selected Other, enter details below:
YesNo
Ethnicity:*
Native HawaiianAsianWhiteOther Pacific IslanderBlackAmerican Indian or Alaska NativeUndisclosed
Full TimePart-TimeUnemployedSelf EmployedRetiredStudentN/AOther
Employer Name:
Employer Phone#:
Format: (000) 000-0000.
YesNo
VeteranVeteran Family MemberN/A
EMERGENCY CONTACT INFORMATION

List Person we may contact in case of emergency.
Name:*

First NameLast Name
Relationship*
Phone Number:*
Format: (000) 000-0000.
Check if OK to leave message at your home phoneCheck if OK to leave message on cell phoneCheck if OK to leave message at work phoneCheck if OK to say we are from HuiMālama Ola Nā ‘Ōiwi when we write or call?
Hui Mālama StaffFamily/FriendPhysician ReferralWebsiteCommunity EventFlyerNewsletterNewspaperSocial MediaSearch EngineOther
If you selected Other, enter details below:
HUI MĀLAMA OLA NĀ ʻŌIWI - Authorization and Release Form
I hereby authorize the release of information which has been obtained about me. I understand that this information will be usedfor statistical purposes and/or to help me receive the benefits to which I may be entitled. My name will not be used, only a code number. *
Type your initials to authorize.
I authorize and consent to any diagnostic and/or medical treatment under the instruction of the attending physician and/ormedical professional for which my dependent or I have sought care.*
Type your initials to authorize.
I give Hui Mālama Ola Nā ʻŌiwi permission to verify the financial and insurance information provided by me to determine eligibility for Hui Mālama Ola Nā ʻŌiwi health services. I understand it is my responsibility to keep Hui Mālama Ola Nā ʻŌiwi informed of any changes in my family’s income and insurance status.*
Type your initials to authorize.
All information on this form is true and accurate to the best of my knowledge:
Type your full name to sign*
Signature (Patient Party / Legal Guardian)
Date:*

MonthDayYear
Date
Witness*
Type witness first and last name

Release, Waiver of Liability, and Indemnity Agreement

In exchange for permission to participate in Hui Mālama Ola Nā ‘Ōiwi (hereinafter referred to as “Hui Mālama”) programs and activities, I hereby enter into the following Release, Waiver of Liability, and Indemnity Agreement. I, for myself, my heirs, spouse, executors, administrators, personal representatives and assignees, WAIVE, RELEASE, DISCHARGE, INDEMNIFY, AND HOLD HARMLESS AND AGREE NOT TO SUE Hui Mālama Ola Nā ‘Ōiwi, its officers, directors, managers, employees, agents, landlords, lessees, sponsors, instructors, representatives, volunteers, and affiliates (hereinafter referred to as “Released Parties”) from, and against any and all liability, responsibility, damages, losses, claims, demands, actions, suits, judgements, costs and expenses (including attorney’s fees) resulting from personal injury, accident, illness, death, and/or property loss caused in any manner, including theft (personal belongings and otherwise), fire, and the simple, active, or passive negligence of the Released Parties, by my participation in all Hui Mālama services and activities.

I am aware that it is my responsibility to check with my physician prior to and regarding my participation in any type of class, presentation, workshop, cohort, event, and/or activity and that my signature verifies that I am physically fit to participate. I understand that there are no medical services available on site or otherwise, and I give my permission to Hui Mālama to authorize emergency medical treatment for me. I release Hui Mālama and its officers, owners, employees, and agents, from liability for any injury or damage that might extend from such emergency medical treatment.

I understand that my participation is voluntary and that photographs, videos and/or audio recordings may be taken before, during, or after Hui Mālama services and activities, for promotional, publicity, or organizational purposes. I expressly authorize Hui Mālama to photograph, videotape, and/or record my voice and sounds; and to use any such photographs, recordings, and reproductions thereof in print, projections, internet websites, videos, or any future media market. I expressly release Hui Mālama or any institution transmitting or exhibiting my picture or my voice from any claims arising from such use or distribution. In addition, I waive the right to inspect or approve the finished product, including written or electronic copies, wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising out of or related to, the use of the photograph/video.
I choose to opt out of photography and video. Type initials below if opting out.
Type your initials if opting out
Terms of this Release, Waiver of Liability, and Indemnity Agreement also applies to any and all minor children in attendance. Parents, guardians, and caregivers are fully responsible for their minor child’s health, safety and well-being while attending Hui Mālama’s services and activities.

I have read this agreement fully and understand its terms. This agreement is intended to be as broad and inclusive as permitted by law.

My signature (for myself and my minor child) is binding to this Release, Waiver of Liability, and Indemnity Agreement from this day forth.
Date:*

MonthDayYear
Date
Parent/Guardian type your full name to sign
Should be Empty:

CONTACT INFORMATION

RESPONSIBLE PARTY INFORMATION

HOUSEHOLD INFORMATION

EMERGENCY CONTACT INFORMATION

HUI MĀLAMA OLA NĀ ʻŌIWI - Authorization and Release Form

All information on this form is true and accurate to the best of my knowledge: