• 2026 Kaukau 4 Keiki Waitlist

    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 that if accepted into the Kaukau 4 Keiki program you will:

  • Agree to receive text reminders for the duration of the program.*

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

  • IMPORTANT NOTE

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

    If a registered 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 registration form
    • An alternate pick-up person listed on the registration form
    • A sibling who is 16 years of age or older and who is also registered for Kaukau 4 Keiki
    • No other individuals are authorized to sign on behalf of a registered child.

  • Parent/Guardian Information

  • Format: (000) 000-0000.
  • Would you like to complete the Medical Statement for Participants with Unique Mealtime Needs form?*
  • Would you like to volunteer (help pack, distribute, etc.) at the site you are picking up from?

  • 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.
  • Format: (000) 000-0000.

  • Child Information

  • Birthdate*
     - -

  • To register additional children, please complete another form.

  • 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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