Request edit access
Assistance Request
The Coordination Center is your first step to support. This form serves as a first point-of-contact for Hawai’i County residents who may need assistance connecting to housing, financial, parenting, and health-related community resources. If you are in need of support, complete the form below. We will contact you within 2 business days to see what services you may qualify for and direct you to support. You may also call or text our Coordination Center at (808) 501-1413.
*Please note this is not an application for services, this is an assessment to connect you to services that may be able to assist* 
*The Emergency Rental Assistance Program is CLOSED*
Sign in to Google to save your progress. Learn more
First Name: *
Last Name: *
Date of Birth: *
MM
/
DD
/
YYYY
Phone Number: *
Can you receive text messages? *
Email:
How many people are in your household? *
How many minors are in your household? (Children under the age of 18) *
Zip Code of last or current permanent address: *
Is your household at or below 80% area median income? *
Captionless Image
Required
What Services Are You Seeking? *
Required
Please Describe Your Request For Services: *
 *By submitting this form, I give Neighborhood Place of Puna the permission to release, obtain and verify all pertinent information with the individuals and agencies offering the services you are requesting. Those who receive this information cannot disclose it to others without further consent. This consent has been made freely, voluntarily, and without coercion. Please click Yes if you give your consent. Once the referral form is received, NPP will follow up within 2 business days.* *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Neighborhood Place of Puna. Report Abuse