KEY Request For Kōkua

Request For Kōkua
This form is designed to help connect you with a network of nonprofit, business, and government partners who may be able to provide support. By completing this form, you consent to sharing your information with KEY Project and its partners for the purpose of identifying potential assistance. Please note that submission of this form does not guarantee services.

NOTE: Our network may not be able to provide direct support for major home or property repairs. We can offer referrals to contractors or service providers who may be available for hire at your own expense if the repairs exceed our capacity.
Name

First NameLast Name
Were you impacted by the Kona Low Storm?

YesNo
Is your home currently uninhabitable as a result of recent flooding?

YesNo
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
Do you own or rent your home?

OwnRent
Household Size
Total number of children under 18 in your home.
Is anyone hāpai in your home?

YesNo
Are any children in your home affected by a disability?

YesNo
Is anyone in your household affected by a disability?

YesNo
Is anyone in your household over the age of 65?*

YesNo
Do you receive SNAP?

YesNo
Are you receiving food supplies from a distribution today?

YesNo
Please indicate what type of assistance you are requesting.
If you are requesting non-urgent medical assistance, please indicate below. Otherwise, please call 9-1-1.
I am requesting medical support.

Yes
Perishables

FoodWaterIcePersonal hygiene items (toilet paper, shampoo, etc.)Baby hygiene items
Clothing Replacement

Yes
My house has sustained damage and I need help cleaning it out.

Yes
Debris removal (outside)

Yes
Completing insurance claim forms

Yes
I need assistance/support with pet related needs

Yes
I am requesting assistance for my registered Ag business

Yes
Have you reported property damage to the Department of Emergency Management? https://www.honolulu.gov/dem/homedamage/

Yes
I want to volunteer for the following opportunities:

Stream clearingDebris removalFood/supply deliveriesI have heavy equipment and am willing to use it during disaster events
No overnight shelters were available on the Koʻolau Coast during the most recent Kona Low because of a lack of trained volunteers. Would you be interested in being trained as an overnight shelter volunteer by the Red Cross or KEY Project?
Shelter Volunteer Training Type

Yes, KEYYes, Red CrossYes, Both
Other notes/information
Please upload images that may help convey your need.

Cancelof
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 the Kualoa-Heeia Ecumenical Youth Project (“KEY”) 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 KEY 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 KEY 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 KEY.

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.
Should be Empty:

Request For Kōkua

Please indicate what type of assistance you are requesting.