A2 Ongoing Registration Form Hoʻāla- Pōhai Makua Parent Program

1. Registration Form: Please read this thoroughly before registering.

Thank you for your interest in participating in Pōhai Makua Parent Program!

We invite you to join our welcoming, non-judgmental gatherings designed for parents, caregivers, and hānai makua. This program provides valuable information and practical strategies to help keep your keiki drug-free.

Program Details:

Days: Every Tuesday and Thursday
Time: 6:00 – 7:00 p.m.
Location: Virtual (via Zoom)
Please ensure that Zoom is installed on your device prior to the first session.

Participation requires that cameras remain on during each session. If you are unable to have your camera on, you will not be accepted into/you will be removed from the program.

In a virtual setting, attendance and participation can only be verified through your virtual presence, or with your "cameras on".

You will receive a Certificate of Completion and a $40.00 gift card, once you complete all seven (7) sessions and complete a pre- and post-survey.

For more information, please contact:
Aunty Momi
📞 808-385-0439
📧 momi@mfss.org

Important:
All application questions must be completed to be considered for participation. Once accepted, you will receive additional details, including the Zoom link for upcoming sessions.

Contact information:

Question Title

Name: (Required.)

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Gender (Required.)

Male

Female

Other

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Your Date of Birth (Required.)

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What is today's Date (Required.)

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Best phone number for us to contact you (Required.)

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Email address: We will primarily communicate through email. Please be sure to provide us with a complete email address and access your email regularly, once accepted into the program. (Required.)

Question Title

Ethnicity (Required.)

Hispanic or Latino

I am NOT Hispanic/ Latino

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Race (Required.)

American Indian or Alaska Native

Black or African American

Asian or Asian American

Native Hawaiian or other Pacific Islander

White

Another race

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Home Address: Verifiable Hawai'i Address Only! (Required.)

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What is the Age, Grade Level, and Name of School of your child? (Required.)

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What is your relationship to this child? (Required.)

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How did you hear about the Pōhai Makua Parent Group? (Required.)

Flyer

Friend

Social Media

MFSS Staff

Other (please specify)

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What island will you be participating from? (Required.)

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Commitment Agreement (Required.)

I understand that this is a multi-lesson program and I commit to attending all seven (7) sessions.

I agree to participate respectfully in a non-judgemental group environment.

I understand that it is required that I leave my camera on for the entirety of all seven (7) session

I understand that completion of this form does not guarantee acceptance.

A2 Ongoing Registration Form Hoʻāla- Pōhai Makua Parent Program

1. Registration Form: Please read this thoroughly before registering.

Question Title

* Name: (Required.)

Question Title

* Gender (Required.)

Question Title

* Your Date of Birth (Required.)

Question Title

* What is today's Date (Required.)

Question Title

* Best phone number for us to contact you (Required.)

Question Title

* Email address: We will primarily communicate through email. Please be sure to provide us with a complete email address and access your email regularly, once accepted into the program. (Required.)

Question Title

* Ethnicity (Required.)

Question Title

* Race (Required.)

Question Title

* Home Address: Verifiable Hawai'i Address Only! (Required.)

Question Title

* What is the Age, Grade Level, and Name of School of your child? (Required.)

Question Title

* What is your relationship to this child? (Required.)

Question Title

* How did you hear about the Pōhai Makua Parent Group? (Required.)

Question Title

* What island will you be participating from? (Required.)

Question Title

* Commitment Agreement (Required.)

Name: (Required.)

Gender (Required.)

Your Date of Birth (Required.)

What is today's Date (Required.)

Best phone number for us to contact you (Required.)

Email address: We will primarily communicate through email. Please be sure to provide us with a complete email address and access your email regularly, once accepted into the program. (Required.)

Ethnicity (Required.)

Race (Required.)

Home Address: Verifiable Hawai'i Address Only! (Required.)

What is the Age, Grade Level, and Name of School of your child? (Required.)

What is your relationship to this child? (Required.)

How did you hear about the Pōhai Makua Parent Group? (Required.)

What island will you be participating from? (Required.)

Commitment Agreement (Required.)