Keiki Survey - Nā Keiki O Emalia

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Nā Keiki O Emalia

Grief Support for Children and Teens

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Keiki Survey

Name

First Last

What part of the island are you from?

What school do you attend?

What grade are you in?

For Interviewer:

To K5

6-12

For Teens

What is your all time favorite thing to do for fun?

What is your worst subject in school?

If you had to eat one food for the rest of your life, what would it be?

What's your favorite app?

Are you a social media fan?

What social platforms do you like the most?

TV

Youtube

TikTok

Snapchat

Insta

other

None

Other Social Platform

Are you volunteering today?

Yes

No

Would you like to volunteer for future events to help the younger keiki that have been affected by the fires?

Yes

No

Are you staying at this hotel?

Yes

No

What do you like and not like about it?

How has the fires affected your family, yourself?

If you could change anything today, what would that be?

How would you improve today’s event?

We're thinking of coming up with a daily texting program where you can opt-in to receive texts from us, you can it stop at anytime. ○ I'm thinking this would be Joke of the Day, Word of the Day, Reminder to Breath, Positive Affirmations. All Maui/local related info. We'd also let you know if there are any upcoming events. Would you be interested in something like this?

If yes, would you like to leave me your mobile number now and we’ll be in touch if this happens?

Yes

No

Phone

For Elementary School Ages

Favorites: Animal, Color, Food, Class, Toy, online or in-person games/sport

What's your favorite thing to do after school or on weekends?

If you could choose, would you rather fly or be invisible and why?

Who brought you here today?

Are you staying at this hotel?

Yes

No

What do you like about it?

What do not like about it?

What’s your thoughts on everything happening these days? Are you able to talk to anyone about your feelings...happy, sad, mad?

If your feelings were the ocean, what would your ocean look like today? giant waves, zero waves, windy white caps?

● On a scale of 1-10 how was your week…1 being junk and 10 being great.

NOTES:

Date

MM slash DD slash YYYY

What is 9 + 2

11

87

230

Δ

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Contact

Cameron Center
95 Mahalani St – Room 10
Wailuku, HI 96793

Mail:
PO Box 1137
Wailuku, HI 96793

Phone:
(808) 214-9832

Email:
contact@nkoemaui.org

Nā Keiki O Emalia is a
501(c)(3) nonprofit organization
ID 47-3859477

Helping Children Heal

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