Keiki 'Ai 'Āina Registration Form
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Guardian First & Last Name (you) *
Keiki First & Last Name (student) *
Keiki Gender *
Residential Zip Code *
Keiki Race *
Housing Status *
Is your 'ohana at or below 150% of the Federal Poverty Line in Hawai'i

1 person: $25,965/year 
2 people: $35,265/year
3 people: $44,550/year  
4 people: $53,850/year 
5 people: $63,135/year 
6 people: $72,420/year 
7 people: $81,705/year
8 people: $90,990/year 
 *
Is your 'ohana enrolled in SNAP Benefits? *
Is your 'ohana enrolled in WIC Benefits? *
What is the Keiki's household type? *
Were you directly impacted by the Maui Wildfires? (Your 'ohana lost a home In Lāhainā or Kula, a family member, a job, or a business.) *
Were you indirectly impacted by the Maui Wildfires? (Your 'ohana experienced disruptions, reduced tourism revenue, supply-chain shortages, increased anxiety and emotional challenges) *
Does this box help your 'ohana eat more foods locally grown or caught by East Maui producers? *
Does this box help your 'ohana eat more foods locally grown or caught by East Maui producers? *
Does receiving this box help reduce worry about having enough food to feed your keiki?  *
Are you willing to be contacted for a testimonial or story about how this free distribution helped your keiki and 'ohana?   *
Email address
Phone Number
Mahalo! Please feel free to add any additional comments here.
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