Registration Form

El fitxer no es pot obrir perquè JavaScript no està activat al navegador. Activeu-lo i torneu a carregar la pàgina.

Registration Form

Please fill out the form below to register, to be read and signed by parent/caregiver for a child participant; or by an adult participant for themselves.

Inicia la sessió a Google per desar el teu progrés. Més informació

Personal Information:

First Name: *

Last Name: *

Other Given Names:

Date of Birth: *

AAAA

Address: *

Phone: *

Email:

Gender:

Male

Female

Prefer not to say

Altres:

Esborra la selecció

Name of Family Doctor:

Are you NZ Citizen? *

Yes

Ethnicity? *

Māori

NZ European

Altres:

Hapū:

Iwi:

Emergency Contact:

First Name: *

Last Name: *

Relationship to participant:

Phone: *

Address: *

Children?

(Please skip this section if you are registering your tamariki for Tamariki Taiea/Reheko Rangatahi)

Please list below the name, age, and gender of your Tamariki.

What Services do you wish to enroll in?

(You may be sent a follow up form for each of the following)

Oranga Whanau (Housing Assessments etc)

Tamariki Taiea & Rehekō Rangatahi (Youth Programme)

Oranga Pēpi/Mama

Ngā Taonga o Matakāoa (Pakeke Programme)

Oranga Wāhine

Oranga Tāne

Maui whakahīhī

Altres:

Obligatori

Medical:

Please select if you have any of the following health conditions:

Heart Condition

Diabetes

Migraine

Epilepsy

Asthma

Dizzy Spells

Fits of any type

Travel sickness

Arthritis

Other

(Please specify)

Are you currently taking any medication? *

Yes (If yes please names of medication and dosage times to be taken)

Altres:

Have you had any major injuries (breaks or strains) or illness (glandular fever etc) in the last six months that may limit full participation in any activities? *

Yes (If yes please specify in other below)

Altres:

Do you have any allergies? (If yes please specify treatment required in answer).

Please outline any dietary requirements *

Is there any information kaimahi should know to ensure the physical and emotional safety of you/ your child? (for example, cultural practices, anxiety, darkness, small spaces) *

Yes (If yes please specify in other below)

Altres:

Are you aware of your consumer rights? *

Yes

Maybe

Are you aware of the complaint process? *

Yes

Maybe

Privacy and Confidentiality:

Manaaki Matakaoa ensures personal patient information is not available without your personal written consent.

Consent: *

I will inform Manaaki Matakaoa as soon as possible of any changes in the medical or other circumstances between now and the commencement of the event/Programme. I give Manaaki Matakaoa Oranga Kopara Team permission to use photographs or videos for future promotion of Manaaki Matakaoa. If the programme participant is involved in a serious disciplinary problem, including the use of illegal substances and/or alcohol, or actions that threaten the safety of others, they will be removed from the Programme immediately. By ticking this checkbox, I accept that all information provided is true and correct and give permission to Manaaki Matakāoa to use this information to provide appropriate care, and services.

Obligatori

Envia

Esborra el formulari

No enviïs mai contrasenyes a través de Formularis de Google.

Google no ha creat ni aprovat aquest contingut. Informa d'un ús abusiu - Condicions del Servei - Política de privadesa

Formularis