Email Personal Information / Fa'amatalaga Patino ia 'Oe: First Name / Igoa Muamua: * Last Name / Fa'aiu: * Gender / Ali'i po'o le tama'ta'i: * Please Select an Option Male / Ali'i Female / Tama'ita'i Fa'afafine Fa'atama Other What is Your Gender? Marital Status / Fa'aipoipoga * Please Select an Option Single / Le'i Fa'aipoipo Couple Married / Fa'aipoipo Divorced / Tete'a Widowed / Maliu le To'alua Are you Single, Married etc? Date of Birth / Aso Fanau * Email Address / Imeli: * Phone Number / Numera Telefoni: * Village / Alalafaga: * What Village Are You From? Children / Fuainumera o le Fanau: * Please Select an Option None 1 2 3 4 5+ Do You Have Children in Your Care? (Under 18) Occupation / Galuega * Please Select an Option Unemployed Employed - Casual Employed - Part Time Employed - Full Time Self-Employed Financial Information / Fa'amatalaga Tautupe: Fortnightly Household Income / Tupe maua aiga i le ta'i lua vaiaso: How much on average does your household bring in fortnightly? Do you ever have trouble making ends meet? / E masagi ona feagai oe ma fa'afitauli o tau seleni i le fa'aiuga o vaiaso?? Please Select an Option Yes, Often Yes, Sometimes No / Leai Do you ever have trouble paying your bills? / E masani ona feagai oe ma fa'afitauli i le totogiina o pili pei o le vai, eletise ma isi? Please Select an Option Yes, Often Yes, Sometimes No / Leai (eg, Cash Power, Phone Credit, Water) Fortnightly Expenses / Tupe fa'alu masani ona fa'aaluina i le totogiina o pili o le moli ma le vai ma isi: (eg, Cash Power, Phone Credit, Water, etc) Is there ever times when you don't have enough food? / E iai se taimi na e maua ai i le le lava o le fa'asoa i mea tau mea'ai taumafa? Please Select an Option Yes, Often Yes, Sometimes No / Leai Do you receive remittances sent from overseas? / E masani na lafo mai ni au tupe mai 'aiga i atunu'u mamao? Please Select an Option Yes, Regularly Yes, Sometimes Yes, But only for fa’alavelave No / Leai Do you have family, friends or spouses overseas send you money? Family Information / Faamatalaga Aiga Lautele: What are the ages of your Children? / E fia tausaga o tamaiti? (eg. 3 months, 3yrs, 4yrs) Do you currently breastfeed a baby or use formula / O e faasusuina lou alo ia oe poo le apa susu? (Pe'ā fai o iai se pepe) Please Select an Option Breastfeed Formula Other / Ma isi What school(s) does your child/children attend? / Igoa o tamaiti ma aoga o lo'o ao'oga ai (fanau uma lava lalo mai le 18 tausaga) Please list all schools your children under 18 attend Are any of your children enrolled in Early Childhood Programs? / E iai sesi o le fanau o lo'o aoga i le aoga tulaga lua? Please Select an Option Yes / 'ioe No / Leai Is your child/children getting the help they need at school and home for their studies? / O maua e le fanau se fesoasoani o lo' o latou mana'omia mo le aoga ma a latou meaoga? Please Select an Option Yes / 'ioe No / Leai Do you help your child/children with their homework? / O e feasoasoani i meaoga a lau fanau? Please Select an Option Yes, Regularly Yes, Sometimes No / Leai Home Situation / Fesili mo le Soifua Maloloina Do you feel safe in your home? / O e saogalemu i totonu o lou aiga? Please Select an Option Yes / 'ioe No / Leai Have you ever filed a Restraining Order? / Sa e faia se tusi taofi i se taimi? (Pei o le tusi saisai po'o se tusi taofi) Please Select an Option Yes / 'ioe No / Leai Do you have a close network of supportive family & friends? / E iai se upega o feso'otaiga o lo'o lagolagoina lou aiga ma uo? Please Select an Option Yes / 'ioe No / Leai Medical Questions / Fesili mo le Soifua Maloloina Do you, or another member in your household live with a chronic illness? / E iai nisi o lou aiga e maua i gasegase o lo'o fa'ailoa atu i lalo? Faamolemole vase pusa pe'a fai e maua i nei ma'i Heart Disease / Ma'i Fatu Cancer / Kanesa Chronic Lung Disease / Afaina Māmā Stroke Alzheimer's Disease / Afaina le mafaufau Chronic Kidney Disease / Afaina Fatuna'o HIV/AIDS Diabetes / Maua le Suka Hypertension / Toto Maualuga Arthritis / Ma'i Gugu Other / Ma Isi None / Leai se ma'i maua ai Check all that apply Were any members of your family affected by the Measles outbreak? / E iai se isi o le aiga sa maua i le Misela? Please Select an Option Yes / 'ioe No / Leai Does your family have any history of chronic illnesses? / E iai se ma'i tumau po'o se fa'amatalaga o se gasegase tumau totonu o le aiga? Are you currently experiencing any of the following? / O maua oe ini auga o lo'o lisi atu i lalo? Dry Cough / Tale ma tiga le fa'a'i Fever / Fiva Headaches / Tiga le ulu Check all that apply How Can Brown Girl Woke Help You? / O le'a se fesoasoani o le matou fa'alapotopotoga o lo'o e mana'omia? How can we help Do You Have Any Questions For Us? / E iai sau fesili? By pressing submit you agree to give us permission to take and publish photos of recipients of our donations for use on our social media platforms and website, your email address will also be added to our mailing list. All Information entered into this form is considered strictly confidential and will not be shared with any 3rd parties. I lou malie ma lou ioeina i fesili uma, E iai le matou 'aiā e mafai ai ona matou pu'eina outou ata fa'atasi ai ma fo'ai aua le ave lea i luga o le initeneti aua le maimoa mai lea o i latou o lo'o fo'ai ma fesoasoani malosi mai i lenei Fa'alapotopotoga ma o lou imeli fo"i o le'a fa'aaopopo i le lisi o tagata o le'a matou taumafai e fesoasoani atu ai i masina ta'itasi. O Fa'amatalaga uma o lo'o fa'amaumau totonu o lenei ripoti e fa'amamafaina le malu puipuia ma e lē mafai ona fa'aaluina i tua pe'ā aunoa ma se fa'atagaina
