Volunteer Kūpuna Trainer Intake Form

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This prototype form in development will be used to screen potential Volunteer Kūpuna Trainers.

First Name *

Last Name *

What Community do you Live in? *

What is your Age? *

Do you have your own Transportation? *

Yes

Check all the areas you would be available to train Kūpuna? *

Princeville, Kilauea, Hanalei, Wainiha areas

Anahola, Kapa'a, Wailua areas

Lihue area

Koloa, Poipu areas

Kalaheo, Eleele, Hanapepe areas

Waimea, Kekaha areas

Other:

Required

At which type of facility would you prefer to train Kūpuna? Please check all that apply. *

Community or Neighborhood Center

Public Library

Church or Faith Based Facility

At the Kūpuna's Home

Homeowner's Association Meeting Room

Community College

High School

Other:

Required

How often would you be able to train Kūpuna?

Once a week

Twice a week

Once a month

Twice a month

Whenever I am needed

Other:

Clear selection

Check all computer technology that you are you familiar with? *

Desktop Computer

Laptop Computer

iPad

iPhone

Android Phone

Other:

Required

How do you access the Internet for information?

I do not access the Internet

I access the Internet from my home computer, laptop or tablet

I access the internet from my Cell phone

I use a friend/family member's computer, laptop, tablet and/or phone

I use a public access hot spot

Other:

Clear selection

Describe briefly why you would like to become a Kupuna iPad Trainer? *

How would you rate your communication skills? *

I have difficulty communicating

I feel that I am a great communicator

How would you rate your empathy skills? *

I have difficulty showing empathy

It is easy for me to show empathy

How would you rate your ability to be patient and not get easily frustrated? *

I am impatient and easily become frustrated

I have a lot of patience and rarely become frustrated

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