Piko Pals Participant Registration
Thank you for your interest in joining Piko Pals! At this time, we have availability for up to 10 parents at each location. Depending on demand, as well as scheduling and flexibility of all applicants and facilitators, we may be able to place you in one of the groups. Please fill out the following questionnaire. We will use the information you provide us to communicate with you, consider your preferences, and coordinate meeting times for your potential group. Congratulations on starting this new and exciting chapter in your life! Mahalo! - Piko Pals
Email address
First Name of Parent Participant
Your answer
Last Name of Parent Participant
Your answer
Street Address
Your answer
Zipcode
Your answer
Phone Number
Your answer
I am a:
Name of participating child: (okay if undecided)
Your answer
Child's birth date (expected date okay)
MM
/
DD
/
YYYY
Names and Ages of other child(ren):
(Start with the youngest first, and separate children with commas)
Your answer
Are there any special accommodations that you or your child needs?
Your answer
Please list any allergies that you or your child have.
Your answer
Newborn Piko Pals Meeting Preferences
Our newborn program is designed for parents and their infants (age 2-12 weeks) to attend together. Groups meet weekly for 2 hours, and are limited to 10 families per cohort. We will try our best to match your preferences to a group in your neighborhood. Group Leader availability ultimately determines group meeting location and time.
What kind of newborn group are you interested in participating? (You may choose more than one option.)
What neighborhood do you live in?/ Where would you like to meet?
Your answer
What time of day are you available to meet? (You may choose more than one option.)
I prefer to meet
Is it okay to share your contact information (name, phone number and email) with other participants in your Piko Pals group?
Would you be open to being trained and supported as a Piko Pals Group Leader to lead your own group in your neighborhood? (Group Leaders do not need to be experts. They do, however, have to be kind, compassionate, supportive, and nonjudgmental. They will introduce discussion topics, help with meeting coordination, and communicate with the Piko Pals Team.)
I authorize Healthy Mothers Healthy Babies Coalition of Hawaii and Piko Pals to use my image for use in future grant applications, publications, brochures, or other materials used to promote Piko Pals?
How did you hear about Piko Pals?
Your answer
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