BGW 2022 Survey

Announcement: Support our Scholarship Program

Apply for Assistance

This form is for individuals and families who require our assistance. We take down your details to add to our database.

Any issues or emergencies please call us 7203887

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Personal Information / Fa'amatalaga Patino ia 'Oe:

First Name / Igoa Muamua: *

Last Name / Fa'aiu: *

Gender / Ali'i po'o le tama'ta'i: *

What is Your Gender?

Marital Status / Fa'aipoipoga *

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: *

Do You Have Children in Your Care? (Under 18)

Occupation / Galuega *

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??

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?

(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?

Do you receive remittances sent from overseas? / E masani na lafo mai ni au tupe mai 'aiga i atunu'u mamao?

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)

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?

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?

Do you help your child/children with their homework? / O e feasoasoani i meaoga a lau fanau?

Home Situation / Fesili mo le Soifua Maloloina

Do you feel safe in your home? / O e saogalemu i totonu o lou aiga?

Do you have access to clean water?

Yes No

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)

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?

Do you have access to electricity?

Yes No

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?

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

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