Request to Join SkillWise
Your name *
Your answer
Please indicate what support you are interested in: *
Your address *
Your answer
Your phone number *
Your answer
Your Cell phone number
Your answer
Your email address *
Your answer
Your date of birth *
MM
/
DD
/
YYYY
Gender *
Ethnicity *
WINZ Number
Your answer
ORRS Number
Your answer
IRD Number
Your answer
Do you have a disability and/or health condition that is/are likely to continue for a minimum of six months. *
Can you please give us some details. *
Your answer
I am eligible for funding from: *
Required
Please indicate what type of assistance you are receiving from Work and Income? *
Required
Do you receive support from another disability provider? *
Required
If you answered "yes", please tell us what provider/s you receive support from
Your answer
Are you eligible to work in NZ? *
Are you funded under a MOH Deinstitutionalisation process? *
I have high and complex needs *
About me and my life
The best way to communicate with me: *
Your answer
I may need support with: *
Your answer
Things I do now *
Your answer
New things I would like to try/do with support from SkillWise or my community.
Your answer
Important People
I live *
The name of your key contact person *
Your answer
Their postal address *
Your answer
Their phone number *
Your answer
Their cell phone number
Your answer
Their email address *
Your answer
Their relationship to you? *
Your answer
The name of a second contact person *
Your answer
Their postal address *
Your answer
Their phone number *
Your answer
Their cell phone number *
Your answer
Their email address *
Your answer
Their relationship to you? *
Your answer
Who is you family/whanau contact (if not one of the above)
Your answer
Their postal address
Your answer
Their phone number
Your answer
Their cell phone number
Your answer
Their email address
Your answer
Their relationship to you
Your answer
Is there anyone else we should know how to contact?
Your answer
Media and Information release
We need your permission to use your image in promotion and to seek other information about you. Please answer yes or no.
I give SkillWise permission to seek information about my medical history, health needs and education. *
I consent to SkillWise using photograph or videos of me. *
Please indicate where we can use your image to promote SkillWise *
Required
Safety and Wellbeing
We need some information to help ensure the best ways to support you. Please answer the following questions.
Who is your current doctor/medical centre *
Your answer
What is their phone number *
Your answer
Do you have any allergies? *
Your answer
Do you currently take any medication? *
If yes, can you tell us what it is?
Your answer
Do you need help to administer your medication?
Are there any behavioural or health issues we should know about? *
If yes, please describe these including any triggers and/or warning signs.
Your answer
Please describe any strategies/steps to help maximise your health and wellbeing.
Your answer
Is it safe for you to drink alcohol? *
SkillWise can at times support people in options where alcohol may be available, we need to know if you can safely drink alcohol.
Submit
Never submit passwords through Google Forms.
This form was created inside of Span Charitable Trust. Report Abuse - Terms of Service