Tamaiti Referral Form

Tamaiti Referral Form
Please complete the following form with the relevant details of the tamaiti you are referring to Hoa Motuhake. All information provided will remain strictly confidential and will only be shared with the assigned sports mentor and relevant Hoa Motuhake staff.

Before submitting a referral, please ensure you have thoroughly reviewed our Memorandum of Understanding (MOU). This document is available on the referral page of our website. Alternatively, you may request a copy by emailing office@hoamotuhake.co.nz.
Date of Referral

DayMonthYear
Date
Tamaiti / Child's Information

Details about the tamaiti being referred.
Full Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Age
Nationality/Ethnicity
If Māori, please specify iwi
School
Home Address

Caregiver's Name

Street Address

CityState / Province

Postal / Zip Code
Secondary Address

Caregiver's Name

Street Address Line 2

CitySuburb
Will your organisation contribute to funding this referral?
Caregiver Information

Details of the child's primary caregiver or legal guardian.
Caregiver's Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email (if known)
example@example.com
Additional Information
Caregiver Consulted?
The caregiver of the tamaiti has been consulted and agrees to support their ongoing participation in the programme and community sport with Hoa Motuhake.
Person we need to contact each week to arrange pick up times

First NameLast Name
Phone Number
Email
example@example.com
Pickup address for child (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referrer Information

Details of the person or organisation making the referral.
Referrer's Full Name

First NameLast Name
Organisation
Branch/Site
Please specify which branch or site you work for.
Contact Number

Area CodePhone Number
Email
example@example.com
How long have you been working with the tamaiti/whanau?
How long do you intend to continue working with the tamaiti/whanau?
Tamaiti / Child's Background & Support Needs

Help us understand the child's current circumstances, strengths, challenges, and support requirements.
What are the current barriers preventing this tamaiti from participating in sport?
Other
Physical Health
Please describe the general physical health of the tamaiti and include any health conditions, needs, or concerns we should know about.
Mental Wellbeing
Please describe the general mental wellbeing of the tamaiti and include any specific concerns or supports we should be aware of.
Behaviour & Social Wellbeing
Please tell us about the general behaviour and social interactions including any specific concerns or support needs we should be aware of.
Medication
Does the tamaiti take any medication? If yes, please specify the medication and its purpose.
Dietaries / Allergies:
Does the tamaiti have any dietary requirements or allergies that we need to inform their mentor about?
Will the tamaiti be available every weekend?
What sport would the tamaiti like to explore?
Current Sport Involvement
Is the tamaiti currently involved in any sports, either through school or in the community?
Additional Information
Please share anything else that would help us understand the tamaiti, such as their interests, personality, whanau circumstances, or any other reasons why they would benefit from our Sports Mentoring Programme.
Attachments

Please attach any supporting information to accompany this referral.
Cancelof
Please allow 2-3 days for your referral to be processed. Once completed, we will contact you to discuss the tamaiti further. If you have any questions, please don't hesitate to contact us at office@hoamotuhake.co.nz.

Thank you for your support.
Should be Empty:

Tamaiti Referral Form

Tamaiti / Child's Information

Caregiver Information

Referrer Information

Tamaiti / Child's Background & Support Needs