Modem Form: Affordable Internet provided by Skinny.
Please note: if you already have, or have previous had a Skinny account using your normal email you will need to create another email account for this Skinny modem.
Street Address Line 2
Postal / Zip Code
Date of Birth
Please enter as many ethnicities as you identify with
In a relationship
How did you hear about Skinny Jump Modem?
Work and Income
Rural Community Organisation
Citizens Advice Bureau
Whanau Ora Navigator
Other Social Services Provider
Health Services Provider
Computers in Homes
Youth Services Provider
Which group(s) do you identify with?
Families with children in low socio-economic communities
People living in rural communities
People with disabilities
Migrants and refugees with English as a second language
Māori and Pasifika youth
Offenders and ex-offenders
People living in social housing
If this Skinny modem is for children, please write the name of the school(s) they attend:
I/We give permission for Whanau Resource Centre to keep basic information relating to myself and my family on a client data base for statistical purposes and to keep a personal file including case notes, in such detail as is necessary to assist Whanau Resource Centre to perform that tasks required providing a service to myself and my family I understand that the information will be stored securely, and that I am entitled to view information on myself to confirm its accuracy. I also give permission for information to be released to other relevant agencies, to the extent that this is necessary and relevant to the service being provided to myself and my Whanau. I understand that this will not normally be done without prior discussion between Whanau Resource Centre and myself. I understand that otherwise all client information is confidential to this agency. However, an exception to this may be made if the agency considers that a child has been abused or is at serious risk of abuse, or that there is a risk to the life or safety of any person.
Please type your name here as agreement to the above statement.
Should be Empty:
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