Youth Wellbeing Programme Registration Form
Registration Details:
Full Name
*
First Name
Last Name
Ethnicity
*
Date of Birth
*
Pronouns (optional)
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Emergency Contact
*
Emergency Contact Phone Number
*
Are you a patient at Kaipara Medical Centre
*
YES
NO
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Medical & Wellbeing Support (Confidential)
Do you currently have a GP?
*
YES
NO
Are you currently receiving any mental health or wellbeing support?
*
YES
NO
Prefer not to say
Is there anything we should know to help support you safely in a group setting? eg (anxiety, panic attacks, neurodiversity, sensory needs, triggers) This information is kept private and only shared with facilitators if needed to keep you safe.
*
Do you have any accessibility needs we should accommodate? Physical- Sensory-Learning-Mental Health - Other please comment below.
*
Food and Allergies - any food allergies or dietary needs?
*
None
Vegetarian
Vegan
Gluten-Free
Halal
Other
Safety, Boundaries & Participation - I understand this is a group space and I agree to:
*
Respect Others
Keep personal stories share in the group confidential
Participate respectfully
Ask for support if I feel unsafe
Do you consent to having photos taken during the programme for reports, social media or website
*
YES
NO
I confirm that: I am aged 17-24, I am choosing to participate voluntarily, I understand the nature of the programme and I can withdraw at any time.
*
YES
Submit
Should be Empty: