Student Information Collection Form

Self Referral Registration Form

2025
Client being Referred Information:
Client Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Ethnicity
Gender
Age
Name of who is making Referral:

First NameLast Name
Relationship to person being referred if not yourself:
Youth Information
School
Any school concerns?

Emergency Contact Information
Primary Emergency | Contact Name

First NameLast Name
Primary Emergency | Phone Number

Area CodePhone Number
Email
example@example.com
Primary Emergency | What is your relationship with this person?

Medical Information
Please list any of the followings: current medications, medication allergies, food allergies, or chronic health concerns.
Do you have to take any medication? If yes please specify
Would you be limited in any way in taking part in physical activities? If yes, please specify
Notes

Referral Reasons
Why are you being referred to us by you? Please describe what is happening for for you. Any trauma's or behavior's we should know (this is confidential)
What would you like us specifically to focus on?
Have you been exposed to / or involved with any of the following:

Domestic ViolenceSexual AssaultOffendingSchool concernsTruancyViolence towards othersMental Health concerns
Please provide information blow on any boxes that have been checked above:
Agency Involvement:

Please list any agencies that have been or currently are working with child (Police / CAMS etc)
Agency 1:
Agency 2:
Agency 3:
Agency 4:
Is there anything else you feel we should know? Please let us know any triggers you have also.
Who do we make contact with to arrange sessions?
Email
example@example.com
Phone Number

Area CodePhone Number
Please upload any supporting documentation:

Cancelof

It is agreed that all care will be taken with my child and/or young person in accordance with the Snapback Gym procedures and I will not hold Snapback Gym or any individual staff members liable for injury or accident or loss of possessions

AgreeDisagree
In an emergency if a parent/caregiver cannot be contacted the Snapback may act on my behalf

AgreeDisagree
Privacy Act

I understand that Snapback will identify any reasonable foreseeable risks and hazards, and implement effective management procedures to eliminate or minimize these.

I know that I am able to ask any questions of the club about the activities for the child will be involved in, to gain a better understanding of the risks involved.

I understand that the club will encourage all ākonga to participate to their full potential, and for some ākonga a support plan will be implemented following discussion with whānau to achieve this.

I understand that behavior will be monitored and support strategies will be put in place to promote the full participation of all ākonga.

I understand the child has been involved in the development of safety procedures and I will do my best to ensure that the child follows these procedures.

The child and I both understand that they may withdraw from an activity if they feel unsafe. This must be done in consultation with the person in charge.

I understand that if the child is involved in a serious disciplinary problem, including the use of illegal substances and/or alcohol, or actions that threaten the safety of others, they will be sent home immediatly.

I understand that the club does not accept responsibility for loss or damage to personal property (either my child’s property or damage to other’s property caused by the child) and that it is my responsibility to check my own insurance policy.
I agree to the above Privacy Statement*

AgreeI Disagree
By completing this referral, you provide your consent for Snapback Gym to share the information provided with other relevant agencies or organizations that may be helpful in providing wraparound support. This includes, but is not limited to, services that may support the individual’s needs and well-being. Your information will be shared only with agencies that are directly involved in supporting the individual and in accordance with privacy and confidentiality regulations. You have the right to withdraw your consent at any time.*

AgreeDisagree
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