Kalauokekahuli Interest in Services Application
Aloha! Please fill out this application to indicate services you are interested in receiving. Although we strive to support everyone, we cannot guarantee that we will be able to fulfill each applicant's needs at this time. However, your application is a valuable resource toward growing Kalauokekahuli's scope of services. Mahalo nui!
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Email *
First Name and Last Name: *
Phone Number: *
Location, Island: *
Estimated Due Date
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As Kalauokekahuli seeks to positively influence prenatal and birth outcomes for Native Hawaiian and Pacific Islanders at this time, are you: *
If you identify as Pacific Islander would you mind specifying your background... *
Please tell us a little bit about yourself/family and why you've come to inquire about our services. Where are you currently in the phases of motherhood; ex. estimated due date, ages of keiki, any complications or special circumstances; any additional pertinent information you feel comfortable sharing. *
We offer both in person and/or virtual means of support in all capacities. We are located on Maui and offer physical care here. Currently all outer island māmā will most likely be receiving virtual support. We are in the process of raising up amazing ko’okua on outer islands to be able to offer physical support very soon! Please indicate the means of service you are open to receiving.  *
Required
Please indicate services you are interested in receiving. (While we may not be able to fulfill all needs, please check all that apply.) *
Required
If answered "other" above, please explain: *
Do you have medical insurance? If so, please state carrier. (Note: Insurance is not necessary to receive our services) *
How did you learn about Kalauokekahuli? *
A copy of your responses will be emailed to the address you provided.
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