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?*

YesNo
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.
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?*

CostTransportLack of confidenceNot having correct equipment/sports gear
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.
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