Contact Details

 
 100% of survey complete.
1. The person who completes this form must note their name. In instances where a whānau member, staff member and or caregiver signs on behalf of the member, that person must note their name and relationship to the member. In the case of children (0 to 15 years), a legal guardian must confirm declaration on behalf of the child.
2. Please ensure that the entire form is verbally read to a kāpō person before completing the form.

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* 1. Date the form has been completed:

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* 2. Are you a new or existing member?

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* 3. Staff or whanau member who is assisting in completing the form:

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* 4. Contact Information

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* 5. Membership Type

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* 6. Date of Birth (dd/mm/yy)

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* 7. Gender

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* 8. Age group at time of Registration

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* 9. Martial Status

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* 10. Ethnicity

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* 11. Aotearoa Maori (please complete below)

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* 12. What is your first language?

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* 13. Medium Preference

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* 14. Are you a member of the Blind Foundation?

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* 15. Are you an ACC Client?

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* 16. NHI Number:

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* 17. Please state your Eye condition(s)

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* 18. When did you notice your issues with your vision?

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* 19. Are you Working?

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* 20. If no, Benefit type:

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* 21. Are you a Diabetic?

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* 22. Do you have any other Disabilities and/or Medical conditions? If yes, please list:

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* 23. Next of Kin Name and Relationship

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* 24. Next of Kin Phone Contact:

INFORMATION CONFIDENTIALITY:
Te Kahui Tumuaki appreciates your cooperation in completing this form. The information you have provided is confidential to Kāpō Māori Aotearoa Inc, and in accordance with the Privacy Act (1993) will not be disclosed without your permission.

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* 25. I confirm that I have been read/read and understand the contents of this form.  I accordingly give my permission for the information contained to be held and used by Kāpō Māori Aotearoa to improve the social and economic status of Māori kāpō and their whanau.

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