Application: Oahu Kaukau 4 Keiki 2023

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Eligible Keiki on Oahu may be eligible to receive a weekly box of breakfasts and lunches to applicants living in specific Oahu rural areas. Keiki 18 and under (or up to 22 years old with a disability and enrolled in HIDOE school).

Email *

Phone Number *

Preferred Email *

Parent/Guardian Information

Name of Parent or Guardian (Last, First) *

Physical Residence Address Including Town *

Zip Code *

Within the past 30 days, our family had worried whether our food would run out before we got money to buy more. *

Often true

Sometimes true

Never true

Don't know / prefer not to answer

Within the past 30 days, the food our family bought just didn't last and we didn't have money to get more. *

Often true

Sometimes true

Never true

Don't know / prefer not to answer

Delivery/ Pickup Information

The list includes authorized areas for rural distribution. Please choose the pickup location that corresponds to your ZIP code for collecting the produce and shelf-stable meals for each student during the summer. If your zip code is not mentioned in the list, it signifies that it was not approved for this particular distribution.

I will pick up my family's box(es) at:
Please select only one. *

Do you have any vacations planned where you will be unable to pick up your box between June 5th and July 31st? *

Meals to Keiki Recipient Information

Please fill out information for each child (Need to create option for more children)

Number of Children in Household *

School (s) attended *

Name of 1st Child (Last, First) *

Birthdate of 1st Child *

YYYY

Ethnicity of 1st child *

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Race of 1st child *

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Name of Child 2nd Child (Last, First)

Birthdate of 2nd Child

YYYY

Ethnicity of 2nd child

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Clear selection

Race of 2nd child

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Clear selection

Name of 3rd Child (Last, First)

Birthdate of 3rd Child

YYYY

Ethnicity of 3rd child

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Clear selection

Race of 3rd child

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Clear selection

Name of Child #4 (Last, First)

Birthdate of Child #4

YYYY

Race of 4th child

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Clear selection

Ethnicity of 4th child

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer

Clear selection

Additional Children Names, Birthdates, Race, and Ethnicity

You must check all the boxes to participate in this program.

By completing this form, you attest that if accepted into the Kaukau 4 Keiki program, you will:

Be the primary caretaker for the child(ren) listed in this application for all purposes, and no one else may claim them for this program

Use the box and its contents to feed your enrolled keiki, using the supplied menus and portion sizes; items cannot be shared with others

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.

Required

A copy of your responses will be emailed to the address you provided.

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