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.
Your Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
Suburb
City
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Ethnicity
*
Please enter as many ethnicities as you identify with
Gender
*
Male
Female
Transgender
Relationship Status
*
Married
Single
In a relationship
Single parent
Other
How did you hear about Skinny Jump Modem?
Work and Income
Facebook
Disabilities Organisation
Salvation Army
Iwi Organisation
Rural Community Organisation
Citizens Advice Bureau
Church
Whanau Ora Navigator
Trade Me
Budget Advisor
Other Social Services Provider
Seniors Organisation
Health Services Provider
School
Training Provider
Computers in Homes
Youth Services Provider
Newspaper Article
Library
Friend
Other
Which group(s) do you identify with?
*
Families with children in low socio-economic communities
People living in rural communities
Seniors
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
Other
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.
Submit
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