Kohala 2026 Kaukau 4 Keiki Waitlist

2026 Kaukau 4 Keiki Waitlist: Kohala

Eligible keiki are 18 and under (or up to 22 years old with a disability and enrolled in an HIDOE school)
By completing this form, you attest to the following:
I am the primary caretaker for the child listed in this application for all purposes, and no one else may claim them for this program.
I will use the food supplies provided to feed my child, using the supplied menu and portion sizes.
My child will not receive summer meals from another USDA Summer Meal program, such as Summer Fun or DOE meal sites; this is considered "double dipping" and is against USDA rules and regulations.
I agree to receive text notifications from Vibrant Hawaiʻi. All communication with Vibrant Hawaiʻi will be made via text message. Please take a moment to create a contact for the Vibrant Hawaiʻi Text Notification in your phone now: 1-808-900-0256.
By completing this form, you attest that you have read and understand the following:
I am registering to be on a waitlist. I will be notified each by text message if I am able to pick up food for my keiki.
I must enter accurate information, including keiki address, birthdate, and my cell number.
I am only eligible to pick up food from a location within my home zip code.

IMPORTANT NOTE

Children who are present at the distribution site may sign the pick-up form themselves.

If a child is not present in the vehicle at the time of pick-up, the pick-up form may only be signed by:
- The parent or legal guardian listed on the form
- An alternate pick-up person listed on the form
- No other individuals are authorized to sign on behalf of a child.
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Parent/Guardian Cell Phone. NOTE: All communication will be sent via text. Please be sure the number entered is correct.
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Alternate Pick Up

You can name (1) other adult to pick up the food on behalf of you/your children. This is the only other person who can pick up meals for the registered child for the duration of the program. Once the application is submitted, this person cannot be changed.
Name

First NameLast Name
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.

Child Information
Child Full Name

First NameLast Name
PHYSICAL ADDRESS (DO NOT ENTER A PO BOX)
CITY
ZIPCODE
SUBDIVISION
Birthdate

MonthDayYear
Date
Ethnicity
Race
To register additional children, please complete another form.
The information provided above is complete and accurate.
Non-Discriminatory Statement

In accordance with federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the state or local agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Mail Stop 9410, Washington, D.C. 20250-9410;
Fax: (202) 690-7442; or
Email: program. intake@ usda. gov.
USDA is an equal opportunity provider, employer, and lender.
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2026 Kaukau 4 Keiki Waitlist: Kohala

By completing this form, you attest to the following:

By completing this form, you attest that you have read and understand the following:

Parent/Guardian Information

Alternate Pick Up

Child Information

To register additional children, please complete another form.