Hawaii Disability Rights Center - Application for Assistance

If you would like to apply for assistance, please complete and "Send" this form to HDRC.


	Last Name:

	First Name:

	Street Address:

	City:

	State:

	Zip Code:

	Phone:

	Email Address:

	Age:

	Birthdate: (MM/DD/YYYY)

	Disability:

	Briefly Describe Your Problem:

	Who is representing you or assisting you with your problem?

If you are having difficulty using this form:

You may request this form over the telephone. Please call:

Or send us the information requested above by email:


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