Notes for completing this form:

 
 50% of survey complete.
1. The person who completes this form must sign it.  In instances where a whānau member, staff member and or caregiver signs on behalf of the registrant, that person must note their name and relationship to the registrant. 

2.  Please ensure that the entire form is verbally read to a kāpō person before completing the form.

Question Title

* 1. Date the form has been completed:

Question Title

* 2. Kāpō Māori Aotearoa staff member assisting in completing the form:

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