ACW Programmes Enrolment Form

Name

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

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Location

Location(Required)

Participant Details

Name(Required)

First Last

Date of birth(Required)

NHI (if known)

Gender

Male / Tāne

Female / Wāhine

Gender Diverse

Address/Mailing Address(Required)

Street Address City Region Post Code

Email(Required)

Phone(Required)

Ethnicity (Please mark the spaces that apply to you)(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 specify)

Ethnicity - Other

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

Country of Birth(Required)

New Zealand

Other (please specify)

Other Country of Birth

Ages of children in your care (if applicable)

Referrer (if applicable)

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.
Share your enrolment information with another organisation where we provide programmes under licence or in partnership.

Participation in the service is voluntary, and I may withdraw myself/programme participant at any stage.

Information about me/programme participant will be kept confidential to Anglican Care Waiapu and partners involved in the delivery of the programme. My information 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)

Name(Required)

First Last

Date(Required)

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Notes

Next of Kin Details

Name(Required)

First Last

Mobile(Required)

Home Phone

Work Phone

Address(Required)

Street Address City Region Post Code

Relationship to Programme Participant(Required)

FOR CHILDREN, YOUTH OR OLDER PEOPLE ATTENDING ACW PROGRAMMES

(To be completed by Parent, Caregiver or Participant)

Medical Awareness

Is there a medical condition we need to be aware of?

No

Yes (please specify)

Medical conditions

Are there any food, or other allergies?

Are there any medications that need to be with the participant during the programme?

No

Yes (please specify)

Medications

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

Does the participant wear a Medic Alert bracelet?

No

Yes (please specify)

Emergency Contact

Name

First Last

Mobile

Address

Street Address City Region Postal Code

Relationship to Programme Participant

School Child Attends

If you have any concerns or questions 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.

Location

Participant Details

Declaration

Next of Kin Details

FOR CHILDREN, YOUTH OR OLDER PEOPLE ATTENDING ACW PROGRAMMES

Medical Awareness

Emergency Contact

FOR GROWING THROUGH GRIEF PROGRAMMES