Seasons For Growth
Enrolment Form - Children & Young People

For programmes NOT run by schools.

1Select a location

2Your details

3More information

4Medical information

5Consent

Location(Required)

Your Details

Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Relationship to child(Required)

Address(Required)

Street Address City Region Post Code

Home Phone

Work Phone

Mobile

Email(Required)

How did you hear about Growing Through Grief?(Required)

Details of child or young person

Name(Required)

First Last

Date of birth(Required)

Age(Required)

Gender

Male / Tāne

Female / Wāhine

Non-Binary

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

Address where child lives (if different from address already entered)

Street Address City Region Post Code

School child attends(Required)

What is the nature of your child’s loss or change in family life?(Required)

Death of a loved one

Separation or divorce of parents

Imprisonment of a family member

Life threatening illness of a family member

Relocation (country, town, school, or home)

Move to alternative care (Oranga Tamariki care, foster care, living with family members other than parents)

Other change in family life or circumstances

Affected by natural disaster

Care / contact arrangements

Please outline the care/contact arrangements for your child where these are relevant. e.g. John lives with me but has every alternative weekend with his mother / father.

Please tell us about any care/contact or family court matters that are pending

(Please note that should we be contacted by solicitors acting for either party we will not be providing any information to them other than confirmation of the child’s attendance).

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

Yes (please specify)

Protection orders in place

Collecting children

It is our policy that children will leave the programme only with people authorised to collect them. To authorise people please record their names and relationship on this enrolment form. If another person is to collect the child, the coordinator must be notified by the custodial parent/caregiver of the change.

I am happy that my child/children may be collected by:(Required)

Name

Relationship

Mobile

I undertake to complete an attendance form each week, noting who will collect my child that day.(Required)

Yes

My child will travel to and from the programme independently each week and I give my permission for them to leave the venue unaccompanied at the end of each session.(Required)

Yes

If yes, travel will be by(Required)

Walking

Bike

Bus

Medical Conditions

Does your child have 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 your child needs during the programme?(Required)

Yes (please specify)

Medications

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

Does your child wear a medic alert bracelet?(Required)

Yes (please specify)

Medic alert bracelet

Child’s doctor’s name

Medical centre

Phone number

Accessibility

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

(e.g., not too long sitting still, not too much writing, easy language, use of te reo Māori)

Yes

They need:

Emergency Contact

Emergency contact(s)(Required)

Name

Phone number

Relationship to child

Parent/Guardian/Caregiver Consent

I consent to my child participating in the Seasons for Growth® programme provided by the Growing Through Grief service/ Anglican Care Waiapu.

I consent to my child’s information being held for the purposes of supporting my child in the programme provided by Growing Through Grief. I understand that any information collected and held by the organisation will be used in a confidential and professional manner in accordance with the Privacy Act 1993.

By signing this consent and declaration I acknowledge, understand, and accept that

The Growing Through Grief Coordinator may:

Use discretion regarding group composition, and limit participant numbers in any programme.
Cancel, postpone, or reschedule programmes or sessions or otherwise vary this agreement if the variation is caused by a reason beyond their control.

The Growing Through Grief coordinator may exclude from the session any child whose behaviour in the group affects the effective delivery of the programme, or the safety, enjoyment, or participation of the other group participants. The suitability of the child's continued participation in the programme will be discussed with the parent/caregiver.
Growing Through Grief services abide by the Anglican Care Waiapu (ACW) Child Protection Policy at all times. Should there be concerns at any time about a child's safety, consideration will be given to reporting concerns in accordance with the Children Act 2014. A copy of the ACW Child Protection Policy is available on request or on ACW's website: acw.org.nz.
Participation in the service is voluntary and I may withdraw my child at any stage.
The information provided on this form is true and correct. I undertake to notify the coordinator of any changes of address, phone number, or family circumstances that occur before or during the programme.

Signed:(Required)

Name(Required)

Relationship to child(Required)

Date:

DD slash MM slash YYYY

Is consent of both parents (guardians/caregivers) required?(Required)

Yes

If yes, please ensure the second consent is confirmed by signature here:(Required)

Name(Required)

Relationship to child(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 for validation purposes and should be left unchanged.

Seasons For Growth Enrolment Form - Children & Young People

Your Details

Details of child or young person

Collecting children

Medical Conditions

Accessibility

Emergency Contact

Parent/Guardian/Caregiver Consent

Seasons For Growth
Enrolment Form - Children & Young People