2025 -  Application Base Data Form 
This online Application Base Data Form is STEP ONE of your process of applying for the 2025 Rotary National Science and Technology Forum - referred to as the 'Forum'.
Applications are invited from New Zealand Citizens or New Zealand Permanent Residents.

All elements of this application form should be completed and submitted at one time.  It cannot be saved and added to later.

INFORMATION TO HAVE ON HAND FOR COMPLETING THIS APPLICATION
  • New Zealand Permanent Residency Number (if not a New Zealand citizen);
  • The name of your nominating Rotary Club to whom your application will be sent;
  • Date of last COVID vaccination;
  • Measles vaccination information
Information provided in this online Application Base Data Form will be treated as CONFIDENTIAL and used only for Forum organisation and management purposes.
Information on Ethnicity and Sex will only be used by Forum management for statistical and sponsorship application purposes.
If you have any questions please contact the Forum Administrator at rotarysciencetechnologyforum@gmail.com
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Email *
Family Name/Surname
(as per an official Identity Document/Passport)
 *
First/Given Name:
(as per an official Identity Document/Passport)
 *
First Name you wish to be known by:
 *
Please select the option which applies to you.
If you are interviewed by the Rotary Club you will need to bring documentary evidence of status with you.
 *
If you are a New Zealand Permanent Resident - please provide the Permanent Residency Number in your passport.
Nationality:
 *
Your personal Mobile Telephone Number (put NA if you do not have one):
 *
Your Home Telephone Number (put NA if you do not have one):
Please include area code, for example, '03' *
Email Address:
 *
Note: Please re-enter your personal email address and NOT a school email address.
This Inbox should be able to receive emails and is checked regularly.
Residential Address (Street Number and Name):
 *
Suburb (put NA if not applicable):
 *
Town/City:
 *
Postcode:
 *
Date of Birth: (DD/MM/YYYY) *
MM
/
DD
/
YYYY
Sex (at birth):
Information on Sex and Ethnicity will only be used by Forum Management for statistical and sponsorship application purposes
 *
Ethnicity: (Select those which apply)
Information on Sex and Ethnicity will only be used by Forum Management for statistical and sponsorship application purposes
 *
Required
Which High School/College do you attend?
 *
What is the name of your nominating Rotary Club that will receive your application?
Your Head of Science, Principal, or school administrator can advise which Rotary club supports your school if you do not know, or do not already have a Rotary club connection. *
Parent/Guardian First Name:
 *
Parent/Guardian Surname:
 *
Parent/Guardian Mobile Telephone Number (put NA if they do not have one)  :
 *
Parent/Guardian Email Address:
 *
Is your home address more than 150 km away from Auckland?
 *
PLEASE NOTE:  Where applicable, the Forum Management will make your travel arrangements, using House of Travel, Milford.  An email from House of Travel, Milford will be used to send you your itinerary and e-ticket/s for travel. If, once you have accepted a place at the Forum, you intend making your own arrangements for travel to and/or from the Forum, please notify us immediately.
The Forum's air and bus travel costs are sponsored and we are accountable to our sponsors for the use of their money.  Any changes to confirmed and paid travel arrangements that incur costs will be charged to your expense.
Nearest Airport/Bus Station
If you answered 'Yes' to the previous question please write the nearest NZ airport offering Air New Zealand flights OR the nearest Intercity Bus Station.
Write NA if this does not apply to you.
 *
If you have a chronic medical condition(s) or allergies (not Food Allergies), please outline below (write 'None' if this does not apply to you)
Food Allergies are asked in the next question
 *
PLEASE NOTE: Health Status information is required to facilitate the provision of appropriate care and ensure student wellbeing.  It is also essential for First Aid, Catering and Forum planning. Failure to declare medical or physical conditions that require ongoing attention and/or assistance could result in your attendance at the Forum being denied or confirmation of attendance being withdrawn.
If you have a Food Allergy/Intolerance and/or related special dietary needs, please outline below  (write 'None' if this does not apply to you)
 *
PLEASE NOTE: Changing dietary requirements when the Forum is underway will not be considered.
Have you received a Covid vaccination?
 *
Date of last Covid vaccination (DD/MM/YYYY)?
 *
MM
/
DD
/
YYYY
Is your Measles vaccination up-to-date?
 *
Date of last Measles vaccination (DD/MM/YYYY)? (where known)
MM
/
DD
/
YYYY
Please select ONE of the following Early Morning Activities in which you will participate, if selected:
 *
If selected, do you wish to attend an Interdenominational Online Church Service on Sunday 19 January 2025?
 *
If selected, a Forum T-shirt will be supplied to you. Please select your T-shirt size:
 *
Please select the following Special Considerations which apply to you?
 *
Required
A copy of your responses will be emailed to the address you provided.
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