We help at Neighborhood Place of Puna!
This program is partially funded from a grant through Department of Human Services (DHS). The Hawaii Diaper Bank (HDB) is partnered with DHS and collects data for reporting purposes only. By completing this application, you consent to release your information to DHS, Blueprint for Change,  County of Hawaii, and the Hawaii Diaper Bank for the purposes of program monitoring and quality assurance. You may withdraw this consent in writing at any time.

Please answer the following questions so that we can find you the best resources to meet you and your family's needs.

After receiving your referral form, we will follow up within 3 business days.
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Email *
First name *
Last name *
Phone number *
Date of birth
 *
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DD
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What is the best way to reach you?
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Required
Referral source *
I need help with...
 *
Required
Are you at risk of losing your housing in the next 2 months? *
Have you been homeless in the last 3 years? *
Are you, or is someone in your household, currently pregnant?
 *
Physical address *
Physical address city *
Physical address state *
Physical ZIP code
 *
What language is spoken at home? *
Do you need an interpreter?
 *
Is this a single-parent household?
 *
Are you employed?
 *
Do you receive SNAP benefits (food stamps)?
 *
Do you receive financial assistance (TANF)?
 *
Have you ever received services from NPP?
 *
Do you reside on the east side of Hawaii? *
Are there any children 0-17 years old in your household? *
A copy of your responses will be emailed to the address you provided.
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