Kauai Volunteer Organizations Active in Disasters (VOAD) Hurricane Lowell - Request for Assistance Intake

Please only fill out one form per household. Takes about 3 minutes. We cannot guarantee support for any specific request.

By submitting this form, you acknowledge and accept that we may share your information with other Kaua'i VOAD partner organizations.  To get you help faster, we share what you have told us with the other Kaua'i VOAD relief organizations, so they can see what you need and reach out if they can help. Only the partner organizations see it.

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Who is filling this out
If this is your own household, this is you. If you are helping someone else, this is you, and we will ask about them next.
Your name *
Organization (if you are not part of an organization, enter NA) *
Your phone number *
Email address (of household, if you have one) *
The household that needs help
If you are asking for help for your own household, put your own name and number here again.
Household contact first name *
Household contact last name
Household phone number
Only if it is different from the number above.
What is your complete residential address? (include street and city/town) *
How many ADULTS are in the household?  *
How many KEIKI (Under 18) are in the household?  *
Is the home safe to stay in right now? *
What Is Needed
What kind of help do you need? (Check all that apply) *
Required
How soon is help needed? *
Provide 1-3 sentences about your greatest needs at this time. *
Anything urgent we should know right now? Any medical needs, medications, or mobility/access needs we should know about?
Best way to reach the household *
Required
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