Wellbeing Skills Short Course Application Form

Wellbeing Skills Short Course Application
Kia ora,

Thank you for your interest in our Wellbeing Skills Short Courses. There are 2 courses available "Connect" and "Grow". This application process will help you determine whether these courses are a good fit for your needs and can be a part of your wellbeing journey.

A Wellbeing Skills Short Course is designed to build on every participant's hauora (wellbeing), to strengthen resilience, grow in confidence and to add new learning, to develop a personal Wellbeing Kete (Toolkit).

These courses are suitable for women aged 16 and over who:

- are motivated to make changes in their life.

- are willing to try new skills and share reflections from these experiences.

Learning is in a group setting; though this is not a therapeutic group, we explore concepts in pschyological terms. Though the difficulties that some participants may currently experience are related to early trauma, this is not a focus of this course.

This course is not suitable for:

- anyone who is currently in an acute crisis, or currently experiencing psychotic

symptoms.

- those experiencing issues with alcohol, drugs, self-harm, eating disorders or

severe anxiety (where these issues are not currently being managed).

It is important that you are applying for yourself, without feeling pressured by others. Your questions are very welcome at any time.

Our team is looking forward to receiving your application and connecting with you.
"Connect" and "Grow" Courses Application
Date of Application

DayMonthYear
Date
1.Your Personal Details
Name*

First NameLast Name
Name you go by (if different from above)

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

Area CodePhone Number
Phone Number (alternative)

Area CodePhone Number
The best way to contact you:
Home Address*

Street Address

Street Address Line 2

SuburbCity

Postal Code
Date of Birth*

DayMonthYear
Age*
Gender*
Ethnicity*
Iwi:
Hapu:
What is your Ethnicity?
Are there any cultural considerations that are important to you, which would be helpful for us to know?
What is your first Language?
English ability?
Emergency Contact Name (optional)

NameRelationship to you
Emergency Contact Phone Number (optional)

Area CodePhone Number
2. About You - Helpful information for us to know
We'd love to know your reason/s for wanting to join this course*
The course utilises experiential learning in a group setting. Do you have experience in a group learning environment?*
What experience do you have in a group learning environment?
The course approach uses talking and written communication to improve a person's wellbeing. Please let us know of any learning difficulty that you experience.
Please list any physical challenges that would prevent you from taking part in mild to medium intensity activity, or in using stairs.
Our approach to Wellbeing is strongly informed by the Te Whare Tapa Wha model with it's dimensions of one's hauora / wellbeing, as developed by Sir Mason Durie.
Have you struggled with, been diagnosed or treated for any mental health related challenges? (e.g. anxiety, depression)*
Please provide details here
Kaupapa

Our desire is that everyone who engages with us would experience unconditional love, and transformative change, resulting in freedom; this is our Christian environment, our Kaupapa.
I have read and understand the Kaupapa for the Wellbeing Skills Short Courses*
3. Practical Aspects Of The Course
Allergies
Please list any food or skin allergies that we need to be aware of.
Getting to the course
Parking at our premises is limited with on street parking not available. If we are unable to provide access for your vehicle, we will run a free pick-up and drop-off service, once a day from a nearby location. Please let us know your preferred option for transport*
Culture of Respect
Our culture values respectfulness of each other by being kind and having consideration for one another. We will address behaviour that is harmful to self or others.*

I have read and understood this.
Our property is a non-smoking, non-vaping, alcohol free and drugs free area.*

I have read and agree to respect this.
Course Costs
As a part of our commitment to reduce financial barriers for participants, our courses are offered at a subsidised rate of $375. This covers all materials and food (morning tea, lunch, and afternoon tea). Please let us know if this seems out of reach for you so we can look at some options for you. We don't want costs to prevent anyone from attending.*
In the following box is our Short Courses Information booklet which has important information for you.
I have read and understood the attached Wellbeing Skills Short Course information document*

YesI have some questions about this
Please let us know your questions and we will get back to you once we receive your application
Completed Application Statement

I confirm, that this application is for myself and to the best of my knowledge the information I have provided is true and correct. I understand that this is a voluntary course and I can withdraw my application at any time.
I have read and understood the completed application statement*

Yes
Signature*

Clear
Name
Date*

DayMonthYear
Date
Privacy: A Girl Called Hope collects and stores information from this form to assess suitability and inform our ongoing work with you while you are engaged with our organisation. Any personal information you provide is collected, held, handled, used and disclosed in accordance with the 12 information privacy principles of The Privacy Act (2020) which can be viewed on the Privacy Commissioner’s website*

I have read and understood this privacy statement
Please be in touch if you have any questions: T 094437136 M 021772168 or Email info@agirlcalledhope.org.nz
Should be Empty:

Wellbeing Skills Short Course Application

"Connect" and "Grow" Courses Application

1.Your Personal Details

2. About You - Helpful information for us to know

Our approach to Wellbeing is strongly informed by the Te Whare Tapa Wha model with it's dimensions of one's hauora / wellbeing, as developed by Sir Mason Durie.

Kaupapa

3. Practical Aspects Of The Course

Allergies

Getting to the course

Culture of Respect

Course Costs

Completed Application Statement