Northland Connect Registration
This registration form is to be completed by everyone participating in the Northland Connect programme. Applicants may get assistance from their programme provider in completing the form.

IMPORTANT NOTE: Northland Connect is for people who have low or no education qualifications, so please check with your provider that you are eligible before completing this form.

"You" in the questions means "the person registering for the programme".
Area *
Participant details
First name *
Your answer
Last name *
Your answer
Gender *
Date of Birth *
Please enter as dd/Mmm/yyyy Example: 24/Jan/1992, 5/Mar/2001 (Month must be one of Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct, Nov, Dec). Make sure you update the year correctly.
MM
/
DD
/
YYYY
Contact details
Information we need to contact you and for running the programme.
Phone (home)
Please start with area code followed by a space e.g. 04 479 8636
Your answer
Phone (mobile)
Please start with code followed by a space e.g. 022 192 3326
Your answer
Postal address 1 *
Flat / House number, Street name Example: Flat 6, 43 Abbott Street
Your answer
Postal address 2
Suburb or Rural locality Example: K
Your answer
Town *
City, town or district Example: Whāngārei
Your answer
Postcode *
Example: 2010
Your answer
Email address (if you have one)
Your answer
What type of internet connection do you have in your home? *
Do you have a computer at home that you can use during the programme? *
What ethnic group do you identify with? *
Do you need any help in understanding English? *
Level of Education *
Refugee or Migrant *
Other information
Any other information you wish to add for this programme. (The box will get bigger as you type.)
Your answer
Promotion *
Declaration
To take part in the Northland Connect programme, I declare that:
- I have not participated in the Northland Connect programme before
- I will take care of the computer
- I will attend 30 hours training
- I will not open suspicious emails or software which may contain viruses
- I will help make the internet a family activity
- I will ask the Northland Connect team for technical support if the computer is not working
- I agree to be contacted and interviewed for research purposes
- I agree that information about my participation in the programme can be sent to Statistics NZ, the Ministry of Education, Tertiary Education Commission, ACE Aotearoa and other Government agencies where it will be used for research and evaluation purposes only
- I agree to 20/20 Trust utilising group text or email to receive updates on my learning journey.
Signed
Your answer
Submit
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