Kahua Program Nomination Form

Kahua Program Nomination Form

NOMINATE YOURSELF OR AN ʻOHANA - The Kahua Card Program provides monthly cash support for one year to Maui fire survivors or fire impacted ʻohana who were left out of traditional aid programs. The program emphasizes trust, dignity and personal agency; letting participants decide how best to use the support received.
Nominator Information / ʻOhana Information*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Last Known Location They Slept / Address:*
Nominee Information*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Fire Impact
1. Was the nominee/ ʻohana directly affected by the 2023 fires?*

YesNo
2. Briefly describe how they were affected (loss of home, displacement, loss of job etc.)*
Previous Support (if known)
1. Did the nominee / ʻohana receive other fire relief support?*

YesNo
2. If yes, for how or how much support did they receive?*
Connections to Service
Has the nominee / ʻohana connected with any of the following? Check all that apply*

Kākoʻo Center with CNHAMaui Medics HuiOur KūpunaTagnawa for MauiKaibigan ng LahainaRoots RebornDCMLong Term Recovery DCMHawaiʻi Community AssetsMaui People's FundCounty of Maui Office of RecoveryHHIP Temporary Housing ProgramFEMA Temporary Housing Program
Other(s):
Why this nominee?
Please share why you feel this individual / ʻohana is a good fit for the Kahua Card Program:*
Vulnerabilities / Challenges
Please check all that currently apply (most participants will be experiencing at least two) :*

Housing insecurity (unsheltered or at risk)Poverty or unstable incomeUndocumented or unverifiable immigration statusMental health needsSubstance use or recoveryCriminal/legal system involvementSole caregiving responsibilitiesChronic illness or disabilityBarriers related to race, language or culture, including LGBTQAI+ identificiation
Other:
Contact and Engagement
Is the nominee / ʻohana wiling and able to remain in contact with us and our Care Navigator at least once per month?*

YesNo
Nominator Signature*

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Date*

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Date
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Kahua Program Nomination Form

Fire Impact

Previous Support (if known)

Connections to Service

Why this nominee?

Vulnerabilities / Challenges

Contact and Engagement