HMST Tamariki Referral Form

Hoa Motuhake Sports Trust Tamariki Referral Form
Please complete the following information for the child you are referring to Special Friends This will be kept strictly confidential by Hoa Motuhake and the sports mentor who will be matched with each child.

It is important that the new MOU document is used in making a suitable referral. This can be supplied upon request by contacting office@hoamotuhake.co.nz
Name of child*

First NameLast Name
Date of birth*

DayMonthYear
Date
Age*
Nationality*
For Maori applicants please specify which Iwi(s) you identify with*
School*
Date of referral*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Will your organisation be contributing to funding your referral*

YesNo
Caregivers Name / Contact Details and additional information*
Address for child to be picked up if different from address above. Usually Saturdays

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Workers Name & Contact Details*

First NameLast Name
Organisation*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Person we need to contact each week to arrange pick up times*

First NameLast Name
Phone Number*
Email
example@example.com
What are the current barriers preventing this child from participating in sport?

CostTransportLack of confidenceNot having correct equipment/sports gear
Other
Parents or care givers have been consulted and are willing to work with the trust during the exit phase to facilitate the child’s ongoing participation in community sport. During this process the trust will work directly with whanau and carers to assist as much as possible.*
Physical Health Issues*
Mental Health Issues: Does the child take any medication. If so, what? And for what purposes *
Behavioural/Social Issues we need to be aware of*
Will the child be available for their mentor or play community sport each weekend?*
What sport would the child like to explore? *
Are they currently involved in a sport*
Any additional information regarding other interests and the child's personality or family circumstances. Reasons why this child is in need of the mentor program.*
Please attach any additional information that could support this referral.

Cancelof
Allow 2-3 days for your referral to be processed. Once completed, we will contact you to discuss the child further. Thank you.

Please don't hesitate to contact office@hoamotuhake.co.nz if you have any questions.
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Hoa Motuhake Sports Trust Tamariki Referral Form