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.
Date the form has been completed:

Question Title

* 1. Date the form has been completed:

Are you a new or existing member?

Question Title

* 2. Are you a new or existing member?

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

Question Title

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

Contact Information

Question Title

* 4. Contact Information

Membership Type

Question Title

* 5. Membership Type

Date of Birth (dd/mm/yy)

Question Title

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

Gender

Question Title

* 7. Gender

Age group at time of Registration

Question Title

* 8. Age group at time of Registration

Martial Status

Question Title

* 9. Martial Status

Ethnicity

Question Title

* 10. Ethnicity

Aotearoa Maori (please complete below)

Question Title

* 11. Aotearoa Maori (please complete below)

What is your first language?

Question Title

* 12. What is your first language?

Medium Preference

Question Title

* 13. Medium Preference

Are you a member of the Blind Foundation?

Question Title

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

Are you an ACC Client?

Question Title

* 15. Are you an ACC Client?

NHI Number:

Question Title

* 16. NHI Number:

Please state your Eye condition(s)

Question Title

* 17. Please state your Eye condition(s)

When did you notice your issues with your vision?

Question Title

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

Are you Working?

Question Title

* 19. Are you Working?

If no, Benefit type:

Question Title

* 20. If no, Benefit type:

Are you a Diabetic?

Question Title

* 21. Are you a Diabetic?

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

Question Title

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

Next of Kin Name and Relationship

Question Title

* 23. Next of Kin Name and Relationship

Next of Kin Phone Contact:

Question Title

* 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.
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.

Question Title

* 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.

T