Raupī te Raupō Registration of Interest Form

Information collected in this form helps us determine eligibility for the Raupī te Raupō early support programme, including participation the research evaluation conducted by Victoria University of Wellington. If you are eligible, you can choose whether you wish to participate or not. Further information will be sent once we have reviewed this form.

By completing this form, you hereby consent to Autism New Zealand collecting your data.

If you would like support to complete this form, please contact the Diagnosis and Early Support Coordinator by emailing: RtR@autismnz.org.nz or calling: 021 190 6053

Privacy Information:

  • Autism New Zealand collects personal information.
  • Information requested and held is for the purposes of providing our services. It may also be used for statistical purposes in a way that doesn’t identify the individual.
  • The information collected will be held securely in our client database and information will remain confidential and available to the Autism New Zealand team only for at least 10 years.
  • Providing information is optional however not providing some details may impact the services that we can offer you.
  • You have the right to ask for a copy of any of the personal information and to ask for it to be corrected if you think it is wrong.
  • Information collected in this form will be shared with Victoria University of Wellington to determine eligibility to participate in the research evaluation.
Parent/caregivers/whānau full name(Required.)
Email address (parent/caregiver)(Required.)
Mobile number (parent/caregiver)(Required.)
Residential address (parent/caregiver)(Required.)
Child/tamaiti full name(Required.)
Child/tamaiti date of birth(Required.)
Child/tamaiti gender(Required.)
What is your child/tamaiti ethnicity/ies(Required.)
What language(s) does your child/tamaiti use at home?(Required.)
Does your child/tamaiti have an official autism diagnosis, if so by who (E.g Private practice, Child Development Services)(Required.)
Does your child/tamaiti have another diagnosis? If so, what?(Required.)
Does your child/tamaiti have any allergies or medical conditions we should be aware of? If so, what?(Required.)