REGISTER

To register for one of our programmes please complete the registration form below.

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Name *

First

Last

Email

Contact Phone Number *

Date of Birth *

Checkboxes *

• Male
• Female
• Prefer not to say
• Transgender

Ethnicity *

• Tongan
• Samoan
• Cook Islands
• Fijian
• Tokelauan
• Niue
• Kiribati
• NZ Maori
• NZ European
• Other

EMERGENCY CONTACT DETAILS *

FULL NAME:

EMERGENCY CONTACT DETAILS *

CONTACT DETAILS:

EMERGENCY CONTACT DETAILS *

RELATIONSHIP TO YOU:

PROGRAMMES, WHICH PROGRAMME ARE YOU REGISTERING FOR? *Rokovi Ira / Elderly ProgrammeWhanau OraEssence of the Pacific Early Learning Centre (ECE)Mens ProgrammeWomens ProgrammeFinancial WorkshopKaukaua YouthHealth ClinicFitness Programme

HEALTH INFORMATION: Do you have any health or physical conditions / Impairments which may affect your ability to participate in the programme? If yes, please describe below. *

• Yes
• No

If yes, please describe below.

IF CHECKBOX YES, PLEASE DESCRIBE BELOW

HEALTH INFORMATION: Have you had any injuries or medical conditions that may aggravate or prevent you from participating in physical wellbeing sessions or other group activities? *

• Yes
• No

If yes, please describe below.

IF CHECKBOX YES, PLEASE DESCRIBE BELOW

Do you have any food allergies? *

• Yes
• No

If yes, please describe below.

IF CHECKBOX YES, PLEASE DESCRIBE BELOW

ROTORUA PACIFIC ISLANDS DEVELOPMENT CHARITABLE TRUST – PRIVACY STATEMENT

I GIVE PERMISSION TO RPIDCT: *

• I AGREE with the RPIDCT Privacy Statement and agree to the terms and conditions.
• I GIVE PERMISSION for photos and videos to be taken of me for RPIDCT organizational purposes
• I GIVE PERMISSION to receive information or be contacted about future services/programmes or events of the Rotorua Pacific Islands Development Charitable Trust

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