Oranga Tamariki - ACC Request Form

Oranga Tamariki - ACC

Request Form
Please select the service you would wish to apply for
Please enter your customer number. You must be already approved by the above service
my customer number is
ONLY government agencies for auditing purposes will have access to the below information
Student's Full Name

First NameLast Name
Student's Birthday

DayMonthYear
Date
Student's School
Parent / Caregiver Full Name:

First NameLast Name
Parent's / Caregiver's Birthday

DayMonthYear
Date
Parent / Caregiver Phone Number
Parent / Caregiver Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Second Emergency Contact Person Full Name:

First NameLast Name
Second Emergency Contact Person Phone Number
Other people's name pick up the child if not the two names above:
People's name NOT authorised to pick up the child:
I Agree
Location would like to enrol
Days would like to enrol (9am-4pm)
Early Drop-off (from 8am)
Late Pick-up (til 5pm)
Lunch order Options （9 options every day):

Please Specify the lunch order options here
I Agree
I consent for use of any photographs or video recordings that are taken of my child while participating in our programs.
Please let us know if your kid have any physical or mental problems, or any other special instructions : (any health and/or medical conditions, including what treatment is required or whether the child is self-medicating, as with asthma.)
Signature
Should be Empty: