Koru Care Otago Nomination form
korucareotago@gmail.com
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Child's Name (as per birth certificate)
Date of birth
Address
Parent/Guardian Applicant Information 
Relationship to child
Name
Address
Email *
Phone Number 
Medical Information 
Please give a brief description of child's health condition
Include physical, intellectual and emotional needs
 *
Other support services involved e.g. special ED etc
Previous Travel
One of our criteria is that the child hasn't travelled overseas before 
Has this child been overseas before?  *
Required
If yes to previous question please give details e.g. Make a Wish, Jingle Bells or similar, family holiday, where, year etc *

Consent 
Can this child travel in the care of Koru Care Otago as part of a group with caregivers?
All the information provided will remain confidential. Completion of this form does not guarantee the nominated child will be chosen for a trip, a full application will need to be completed.
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