Workshop Registration Form 🌱✨🎉
Join us for health and wellbeing workshops; complete the form to register and be contacted.
Registration details
Full Name
*
First Name
Last Name
Preferred Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Auckland Suburb You Currently Live In
*
Which best describes you?
*
Please Select
Te Ora Puāwai customer
Community member
Whānau/support person
Health professional/service provider
Other
Organisation you will be representing
Workshop and attendance details
Which workshop would you like to register for?
*
Please Select
30th July Diabetes Workshop 10am - 1pm Te Puke Otara
27th August Hypertension/Heart Health 10am - 1pm OMAC Otara
24th September 10a- 1pm - OMAC Otara
29th October - Gout - 10am - 1pm- OMAC Otara
26th November - Understanding Medications - 10am - 1pm - OMAC Otara
Are you registering for yourself or on behalf of someone else?
*
Myself
Someone else
Myself and a whānau/support person
Will you be bringing a family member, friend, or support person with you?
*
No
Yes
Unsure
Are you currently a customer of Te Ora Puāwai?
*
Yes
No
Unsure
Would you like to know more about Te Ora Puāwai’s free support services?
Yes
No
Maybe
Health, enrolment, and support needs
Are you currently enrolled as a patient with Ōtara Family and Christian Health Centre?
*
Yes
No
Unsure
If no, which GP clinic or medical practice are you currently enrolled with?
Do you currently manage any long-term health conditions?
*
Yes
No
NHI Number
Ethnicity
Do you have any food allergies or dietary requirements?
*
No
Yes, please specify
Do you need any support to attend or participate in the workshop?
*
No
Yes, please specify
Is there anything else we should know before you attend?
Submit
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