Application: Kaua‘i Kaukau 4 Keiki

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Kaua‘i Kaukau 4 Keiki provides a weekly food box deliveries to applicants living in rural areas on Kaua‘i (Zipcode starting with 967-). The program provider for Kaua‘i is Mālama Kaua‘i.

Email *

Parent/Guardian Information

Name of Parent or Guardian (Last, First) *

Telephone Number *

Email Address *

Delivery Information

Address information will be used to provide a weekly delivery of produce, protein, bread, and milk for each student throughout the summer. If you will not be home, please be sure to provide a cooler for the driver to put your products into. Eligible zip codes for delivery start with 967-

Zip Code *

Delivery Address (Street Address) *

Delivery City *

Delivery Instructions

Include any specific delivery instructions (e.g. upstairs/downstairs, color of house, where to leave boxes)

Kaukau 4 Keiki Recipient Information

Please fill out information for each child

Number of Children in Household *

School (s) attended *

Name of Child #1 (Last, First) *

Birthdate of Child #1 *

YYYY

Name of Child #2 (Last, First)

Birthdate of Child #2

YYYY

Name of Child #3 (Last, First)

Birthdate of Child #3

YYYY

Name of Child #4 (Last, First)

Birthdate of Child #4

YYYY

Name of Child #5 (Last, First)

Birthdate of Child #5

YYYY

Additional Children Names and Birthdates

Would you like shelf-stable milk included in the meal kit? *

Yes

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Prefer not to say

Race *

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to say

Other:

A copy of your responses will be emailed to the address you provided.

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