Request For Assistance

Request For Assistance
This form is to assist a coalition of nonprofit, business, and government agencies that may be able to provide assistance. By completing this form, you agree to share your information with partners of Vibrant Hawaiʻi who may be able to assist, and you acknowledge and understand that assistance is not guaranteed.

NOTE: Our network of providers are unable to assist with roof repair and are limited to providing a list a contractors who may be available for hire, at your own expense.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Physical Address: Do Not List a P.O. Box

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OwnRent
Household Size
YesNo
YesNo
If you are requesting non-urgent medical assistance, please indicate below. Otherwise, please call 9-1-1.
Yes
Please indicate what type of assistance you are requesting.
FoodWaterIce
Yes
Yes
Yes
Yes
Yes
Yes
Other notes/information
Assumption of Risk and Release of Liability

The property owner or resident (“Participant”) understands that assistance activities provided in response to the recent Kona Storm may involve inherent risks, including but not limited to use of tools or equipment, debris removal, and exposure to environmental or site-specific hazards.

By requesting and accepting assistance from Vibrant Hawaiʻi (“VH”) and its staff, volunteers, partners, or contractors, Participant acknowledges and agrees that this assistance is provided in good faith as a community service. Participant understands that VH does not guarantee the condition, safety, or outcome of any work performed, services provided, or recommendations made.

Participant agrees to release, indemnify, and hold harmless VH and its employees, volunteers, agents, contractors, and representatives from any claims, damages, losses, or expenses (including reasonable attorneys’ fees) arising out of or related to the activities conducted at the property, except to the extent caused by the gross negligence or willful misconduct of VH.

Participant further acknowledges that they remain responsible for the ongoing condition, maintenance, and safety of their property and any systems, structures, or equipment located on it.
My signature below indicates I understand and agree to the Assumption of Risk and Release of Liability.

Clear
Should be Empty:

Request For Assistance

Please indicate what type of assistance you are requesting.