DGFG Registration Form (New)

First Name*

Last Name*

Date of Birth*

Gender*

MaleFemaleOther

Ethnicity*

OptionSamoa

OptionTokelauan

OptionTonga

OptionKiribati

OptionFijian

OptionNZE

OptionNiue

OptionMaori

OptionCkIsl

OptionChinese

OptionTuvalu

OptionIndian

OptionOthers

Email*

Phone Number

Work Number

Unit/Street Number*

Street*

Suburb*

City*

Post Code

What is the highest qualification you have achieved?*

Have you ever experienced expulsions or stand-downs from school, or been asked to leave school?*

YesNo

Please note what your passions and aspirations are and explain why in details? (e.g. Sports or Activist)*

Please select the program you wish to attend.*

• Community sport pop ups• Creative sessions• Changemakers programme (Leadership and Wellbeing)

OptionCommunitySport

OptionCreative

OptionChangeMaker

Have you ever been convicted of a crime or had any involvement with the Youth Justice System?*

YesNo

(If yes; please provide a list of the offences or your involvement in chronological order, starting with the most recent incident: Please also include any recent involvement with the Police where the “Alternative Action” pathway was taken).

Instagram Handle

Facebook Handle

Emergency Contact*

Emergency Contact Number*

Do you have any medical conditions?*

YesNo

Please advise what your medical condition is AND if you take regular medication for it*

Do you need support with taking your regular medication? For example, assistance to take a inhaler?*

YesNo

Are there any other health concerns you may have that we need to be aware of?*

Media Consent*

YesNo

Newsletter*

YesNo

Evaluation Consent*

YesNo

We care about your privacy and want you to be familiar with the information we collect, use and disclose. By enrolling in a programme with The Cause Collective, you agree to the following terms:

We collect personal information from you for programme administration and management. This may include your name, date of birth, ethnicity, gender, contact details, location, role, responses to surveys, learning results.

We collect your personal information in order to:

Contact you about relevant content and services
Inform our training programmes
Gather research and statistical information
Carry out the functions for which we collected it, or if required by law.

We are committed to safeguarding your personal information and will take all reasonable steps to protect it from unauthorised access, disclosure, alteration or destruction.

You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be updated at any time. If you would like to ask for a copy of your information, have it updated or to make a general inquiry about your personal information, please contact privacy@thecausecollective. org.nz

We may disclose your personal information to third parties where required by law or contractual obligations.

We will retain your personal information for as long as necessary to fulfill the purposes for which it was collected and in accordance with legal requirements.

I acknowledge that I have read and understood this privacy disclaimer and consent to the collection, use and disclosure of my personal information as described above.

I consent to the above information being used for the purposes stated above*

YesNo

Please verify that you are human*

WELCOME TO DO GOOD FEEL GOOD

Contact Details:

Address Details:

Training, Education and Employment:

Passions and Aspirations

Programs

Police Involvement:

Social Media Details:

Emergency & Medical Details:

Media Consent:

Newsletter:

Evaluation Consent:

Consent: