HMHB Emergency Resource Request Form for Affected Families
Aloha, this form is intended for families impacted by the recent Kona Low Storm and flooding. Please complete the information below to request assistance with essential needs. Healthy Mothers Healthy Babies Coalition of Hawaiʻi will review your request and reach out with available support as soon as possible.
'Ohana Name
Number of people in household. Ex. 2 adults, 2 keiki. Please include the age and gender of each child.
Is anyone in the household currently pregnant?
Yes
No
What island are you on?
Oahu
Maui
Moloka'i
Lana'i
Hawai'i Island
Kaua'i
What is the address of the impacted property?
How were you impacted by the storm?
Displaced from home
Severe damage to home/property
Minor damage to home/property
Other
Explain why assistance is needed and where damage took place. This information is being collected solely for funding purposes.
What are you in need of?
Food
Clothing
Diapers
Car Seats
Strollers
Cribs/Pack-n-Play
Breastfeeding/Postpartum Supplies
Household Items
Medical Support
Other
If you selected clothing, diapers, or "other", please provide sizes and any additional information below:
Shared by *For verification only. Not shared publicly*:
We are the displaced 'ohana
I know this 'ohana and personally vouch for them
Sharing but haven't personally verified
HMHB Staff Submitted
Name (HMHB staff or person vouching for family)
Contact info for follow-up and verification. Name & phone number. *Not shared publicly*
Submit
Should be Empty: