Deaf Mentor Family Intake Form
Aloha! The Deaf Mentor Pilot Project (DMPP) has been established to provide ASL instructional services, consultation, mentorship, and advocacy as appropriate and based on the individual needs of children birth to 3 years old and families who have been authorized to receive these services by the DOH-EIS. Criteria has been determined by DOH-EIS. Please fill out this form so we can pair you with a deaf mentor or to receive additional information. Please feel free to contact Roz Kia at
or (808) 284-3551 if you have any questions. Mahalo!
Family Last Name
Parent/Guardian Name (Primary contact)
Deaf/Hard of Hearing Child's Name and Age
Names and ages of other children in the home
What is the name of your Early Intervention specialist?
What is his/her contact information?
Please select one.
I am interested in participating in the Deaf Mentor Pilot Project.
I am unsure and would like more information.
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