Enrol in a Grief Support Programme NZ

Instagram

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

This field is hidden when viewing the form

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)

This field is hidden when viewing the form

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)

Type of Medic Alert bracelet:

Emergency Contact (If different from Next of Kin)

Name

First Last

Mobile

Address

Street Address City Region Postal Code

Relationship to Programme Participant

Accessibility

No

Yes (please specify)

We want our programme to be safe and accessible to everyone. Is there anything that would help in attending this programme? e.g., not sitting still for too long.

Accessibility requirements:

Enrolment Form

Location

Participant Details

Declaration

Next of Kin Details

FOR CHILDREN, YOUTH OR OLDER PEOPLE ATTENDING ACW PROGRAMMES

Medical Awareness

Emergency Contact (If different from Next of Kin)

FOR GROWING THROUGH GRIEF PROGRAMMES