Free Mask Request Form
We are distributing free non-medical grade, non-reusable, disposable face masks on a first come first served basis to patients, survivors, and their families. KN95 masks are also available for those in active treatment. Due to limited supply, each family will be limited to 5 face masks. Must be a resident of the state of Hawaii. 
First Name *
Last Name *
Email *
Phone number *
Address *
(ex: 123 Main St.)
City *
State *
Must be a resident of the state of Hawaii
Zip Code *
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