Registration number:__________________________
Office use
Waitaha Sports Grant
To be applied for by Uri o Waitaha, if not registered head to our website to do so. This Grant is to be applied for by an individual and not as a team.
1. I am applying for:
Please Select
Myself (Pakeke Reps)
My Tamaiti (1)
My Tamariki (2+)
2. Full Name (Person filing in the form)
*
First Name
Last Name
3. Date of Birth
-
Month
-
Day
Year
Date
4. Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
5. Phone Number
*
Format: (000) 000-0000.
6. E-mail
*
example@example.com
7. Child(ren) I am applying for:
(If applying for yourself please leave this section blank and head to Question 9)
Child 1
Full name
Date of Birth
Sporting level:
Please Select
Under 18yrs old Local sport $100 Max
Under 18yrs old Representing a region ie: BOP $300 Max
Under 18yrs old Representing Aotearoa- Up to $1000
Pakeke 19+ Representing Aotearoa up to $1000
Child 2
Full name
Date of Birth
Sporting level:
Please Select
Under 18yrs old Local sport $100 Max
Under 18yrs old Representing a region ie: BOP $300 Max
Under 18yrs old Representing Aotearoa- Up to $1000
Pakeke 19+ Representing Aotearoa up to $1000
Child 3
Full name
Date of Birth
Sporting level:
Please Select
Under 18yrs old Local sport $100 Max
Under 18yrs old Representing a region ie: BOP $300 Max
Under 18yrs old Representing Aotearoa- Up to $1000
Pakeke 19+ Representing Aotearoa up to $1000
Child 4
Full name
Date of Birth
Sporting level:
Please Select
Under 18yrs old Local sport $100 Max
Under 18yrs old Representing a region ie: BOP $300 Max
Under 18yrs old Representing Aotearoa- Up to $1000
Pakeke 19+ Representing Aotearoa up to $1000
Child 5
Full name
Date of Birth
Sporting level:
Please Select
Under 18yrs old Local sport $100 Max
Under 18yrs old Representing a region ie: BOP $300 Max
Under 18yrs old Representing Aotearoa- Up to $1000
Pakeke 19+ Representing Aotearoa up to $1000
NB:
All tamariki named above, if not already registered under your name (in Q2) will be naturally added to your registration. If the tamariki are registered under another Waitaha Uri please list their name(s) below or email education@waitaha-iwi.org.nz.
8. Name of Caregiver/Parent/Whanau Tamariki listed above are registered under (if not named in Q2):
Name 1
Name 2
9. Pakeke at a representative level:
Please Select
Yes 19+ Representating Aotearoa- $1000
No (We only Grant Pakeke when they're at reps level)
10. Tell us about your kaupapa (Include team name) any dates we could come to Tautoko you. How this putea will be a helpful contribution:
*
11. Please supply: A quote and/or paid invoice/receipt
*
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12. Please supply: An account number and correct name matching the account. This can be a screenshot from your internet banking with the logo in it, or a letter from the bank.
*
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13. Please supply: The applicants (Q2) Identification
*
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Conflict of Interest (COI'S) Do you have any Conflicts of Interest to declare? Are you related to anyone in the Office or on the Sub-Committee I.e: Spouse, Sibling, Parent, Child or 1st cousin?
Yes
No
Please name all COI'S here:
Signature
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