Seasons For Growth Enrolment Form - Adult

This field is hidden when viewing the form

Programme Details

(facilitator to complete this section)

This field is hidden when viewing the form

Meet and greet date

Day

Month

Year

This field is hidden when viewing the form

Programme date

Day

Month

Year

This field is hidden when viewing the form

Programme Venue

Location(Required)

Your Details

Name(Required)

First Last

Date of birth(Required)

Gender

Male / Tāne

Female / Wāhine

Non-Binary

Address(Required)

Street Address City Region Post Code

Email(Required)

Phone(Required)

Ethnicity(Required)

For statistical purposes always use Māori or Pacific as primary ethnicity if more than one ethnicity.

New Zealand European / Pākehā

Māori

Samoan

Cook Island

Tongan

Niuean

Indian

Chinese

Other (Please state e.g., Dutch, Japanese, Tokelauan)

Ethnicity - Other(Required)

Country of Birth(Required)

New Zealand

Other (please specify)

Other Country of Birth

Ages of children in your care (if applicable)

Referrer (if applicable)

How did you hear about the Growing Through Grief service?

What is the nature of the loss or change in your life?

Death of a loved one

Separation or divorce

Imprisonment of a family member

Life threatening illness of a family member

Relocation

Other loss or change in family life or circumstances

Are there any protection orders in place in regard to you or your family?

Yes

Medical Conditions

Is there a medical condition we need to know about?(Required)

Yes (please specify)

Medical conditions

Are there any food, or other, allergies?(Required)

Are there any medications that need to be with you during the programme?(Required)

Yes (please specify)

Medications

Please ensure medications are in the original packaging and have instructions with them.

Do you wear a medic alert bracelet?(Required)

Yes (please specify)

Medic alert bracelet

Family doctor’s name

Medical centre

Phone number

Accessibility

We want our programme to be safe and accessible to everyone. Is there anything you need that will help you enjoy, learn and benefit from the programme?(Required)

(e.g. an accessible venue, large print, easy to read information)

Yes

I need:

Emergency Contact

Name(Required)

Phone number(Required)

Address(Required)

Street Address City Region Postcode

Relationship to programme participant(Required)

Declaration

I acknowledge, understand and accept that by signing this declaration Anglican Care Waiapu may:

Cancel programmes and limit participant numbers in any programme
Cancel, postpone or reschedule programmes or sessions without notice
Otherwise vary this agreement if the variation is caused by a reason beyond its control

Participation in the service is voluntary and I may withdraw myself /programme participant at any stage. Information about you/the participant will be kept confidential to Anglican Care Waiapu in accordance with the Privacy Act 1993 and would only be shared with anyone outside the organisation if we had serious concerns about the safety of you, your child/ren or the programme participant.

That the information provided on this form is true and correct.

Signed:(Required)

Date:

DD slash MM slash YYYY

If you have any concerns about the service received and you have not been able to resolve this directly with the staff member concerned, we encourage you to take your concern to the Service/Programme Manager.

This field is hidden when viewing the form

Notes

Comments

This field is for validation purposes and should be left unchanged.