• KidzaCool Adventures - Additional Child Application

  • Child and Caregiver Details

  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Ethnicity*

  • The number of households they live in is:*
  • Tamariki mokopuna (child) has lived with current caregiver(s) since:
     - -
  • Do you have legal custody/guardianship for the child?*

  • Details of all people living at child’s address

    Please include other children and note if the person is a Legal Guardian
  •  -
  • Does the tamariki mokopuna live with anyone other than the people listed in the First Child Application referral form?*
  • Tamariki mokopuna lives with (including all other children):
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  • At the moment, these are the people they cannot have contact with:
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  • If the legal guardian does not live at the child’s address, please provide the contact details of all legal guardians as we are required to advise all legal guardians of our service involvement.

  • Legal Guardian(s) not living at child's address
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  • General Information

  • To help us support your tamariki mokopuna (child), please fill out the prompts to let us know what might be challenging for them, what triggers big feelings, and what helps when things feel hard.

  • Due to illness or changes in plans, some may choose to cancel or defer their attendance. We want to make sure those who are on the waitlist can have an opportunity to attend if available. Would you be available to bring your tamariki mokopuna (child) at short notice should a place become available? If so, what is the best contact number?*

  • Behaviour and Health Checklist - Part 1

    Full disclosure of the following behaviours is required to enable an accurate assessment of the level of support your child may need and ensure we can provide a safe environment for all children attending the programme.
  • Does Your Child Often Lose Their Temper?*
  • Does Your Child Often Argue with Adults?*
  • Does Your Child Often Defy or refuse adult requests or rules?*
  • Does Your Child Often deliberately do things to annoy people?*
  • Does Your Child Often blame others for own mistakes?*
  • Does Your Child Often get touchy or annoyed by others?*
  • Does Your Child Often seem angry or resentful?*
  • Does Your Child Often act spitefully or vindictively?*
  • Does Your Child Often swear or use obscene language?*
  • Does Your Child Often lie?*
  • Does Your Child Often skip school?*
  • Does Your Child Often initiate physical fights?*

  • Behaviour and Health Checklist - Part 2

  • Has Your Child run away from home?*
  • Has Your Child run away from class?*
  • Has Your Child run away from school?*
  • Has Your Child been stood down from school?*
  • Has Your Child broken into someone's house or car?*
  • Has Your Child deliberately destroyed someone's property?*
  • Has Your Child deliberately destroyed their own property?*
  • Has Your Child been physically cruel to animals?*
  • Has Your Child been physically cruel to people?*
  • Has Your Child used a weapon in more than ONE fight?*
  • Has Your Child deliberately set fires?*
  • Has Your Child deliberately stolen?*
  • Has Your Child displayed inappropriate sexualised behaviour?*

  • Health Information

  • Has the tamariki mokopuna (child) been diagnosed as having any of the following Physical conditions?*

  • Currently taking any medication relating to a Physical condition - if yes please list below
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  • Has the tamariki mokopuna (child) been diagnosed as having any of the following Mental conditions?*

  • Currently taking any medication relating to a Mental condition - if yes please list below
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  • Has the tamariki mokopuna (child) been diagnosed as having any of the following Developmental conditions?*

  • Currently taking any medication relating to a Developmental condition - if yes please list below
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  • Does the child suffer from any allergies e.g. food, bites, stings or medications?*
  • Child's Allergies*
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  • Is the child currently taking any medication?*
  • Child's Medication*
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  • Has the child had contact recently (within the last three months) with any infectious diseases e.g. Mumps, Measles, Chicken Pox?*
  • Has the child been fully immunised?*
  • Age immunisation next due?

  • Community Services Card Details

    This is required should the tamariki mokopuna (child) need medical care/prescriptions while at the village.
  • Community Services Card:*
  • Is your child covered?
  • Expiry Date:
     - -
    2 digit day, 2 digit month, 4 digit year

  • Consent to Administer Medications and Seek Medical Treatment

  • To administer my/our tamariki mokopuna (child) prescribed medications:*
  • To administer general health care and/or first aid for my tamariki mokopuna (child) while in the care of Stand Tū Māia (general health care and/or first aid could include; paracetamol/antihistamine/plasters/antiseptic cream etc.)*
  • To authorise emergency medical or surgical treatment for my/our tamariki mokopuna (child) should the need arise and in the case that I/we are unable to be contacted.*

  • Consent for Kidzacool Adventure Programme

  • I/we give permission for my/our tamariki mokopuna (child) to be referred for the Stand Tū Māia KidzaCool Adventures programme.*
  • I/we agree to my/our tamariki mokopuna (child) attending the Stand Tū Māia Village and/or receiving therapeutic activities.*
  • I/we understand that Stand Tū Māia staff will take all reasonable steps to safeguard my/our tamariki mokopuna (child) personal property. However, Stand Tū Māia will not be held responsible for any accidental loss or damage to their personal property.*
  • I/we give permission for my/our tamariki mokopuna (child) child’s photograph to be taken and held securely on Stand Tū Māia devices and internal systems, for the purpose of identifying them in case of an emergency.*
  • I/we give permission for my/our tamariki mokopuna (child) to be transported by Stand Tū Māia staff as is needed for programmes and activities.*
  • I/we give permission for my/our tamariki mokopuna (child) to use technology for educational/therapeutic purposes with supervision of Stand Tū Māia staff (acknowledging that all care will be taken to protect them from offensive, illegal or dangerous material).*
  • I/we give permission for Stand Tū Māia staff to document information and observations for the purpose of providing an overview of their stay.*
  • I/we give permission for my/our tamariki mokopuna (child) to complete a Kidzacool satisfaction survey at the end of their stay.*
  • I/we agree to complete Kidzacool Carer satisfaction survey at the end of my/our tamariki mokopuna (child) stay.*
  • I/we agree to our tamariki mokopuna and whanau information being used (without identifying our whanau) for the purpose of reporting, reviewing and evaluating Stand Tū Māia Services and for contribution to research that supports best practice.*
  • I/we give permission to OBTAIN and RELEASE relevant information to any referring agent identified in this application which may assist with any follow-up for my/our tamariki mokopuna (child) if required.*

  • Consent for Participation in Higher-Risk Activities

    Note: Not all activities listed below may occur

  • Water Based Activities

  • Swimming (pools, beaches, lakes & rivers)*
  • Kayaking/Canoeing*
  • Boating*

  • Wheel Based Activities

  • Biking/scooters*
  • Rollerblades/skateboarding*
  • Horse Riding*
  • Marae Visits (sleepover)*
  • Camping overnight (away from site)*
  • Please let us know if there are any specific precautions or considerations, we should be aware of for your tamariki mokopuna (child) regarding the activities listed above
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  • I understand that Stand Tū Māia staff will take all reasonable steps to safeguard my tamariki mokopuna's (child's) personal property while on the programme. However, Stand Tū Māia and their staff will not be held responsible for any accidental loss or damage to my tamariki mokopuna (child) ’s personal property.*
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