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Good Neighbour Urban Mahi Day Referral Form
Date
*
Full Name
*
First name
Last name
Address
*
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Home phone
Cell phone
*
Email address
*
Date of Birth
*
Gender Identity
*
Another Gender
Female
Male
Prefer not to say
Ethnicity
African
Chinese
Cook Islands Maori
Fijian
Indian
Latin American
Māori
Middle Eastern
Niuean
NZ European
Other Asian
Other European
Other Pacific Peoples
Samoan
Southeast Asian
Tokelauan
Tongan
Emergency/Alternate Contact
*
Total Number of People in Household
Number of Adults in Household
Number of Children (Under 18) in Household
Referred to us by (if applicable)
Name
Agency
Phone
Email
How did you hear about Good Neighbour?
PROJECT DETAILS
Reason for Needing Help
Details of Project
Are there any hazards at your house?
*
E.g. Dogs, large gates or fences...
Yes
No
Hazards
OTHER INFORMATION
Your Current Accommodation
Boarding
Private Rental
Housing NZ Rental
Accessible Properties Rental
Own Home/Mortgage
Own Home/Freehold
No Fixed Abode
Income Source
Wages
Salary
Self-Employed
Seasonal/Casual
Benefit
Is it okay for you/your children to appear in photos for Good Neighbour promotional purposes
When necessary, is it okay for us to share your contact details with a Good Neighbour volunteer to help with co-ordination, planning and follow up.
On assessment of job, a payment may be required. If so, I agree to pay this prior to or on the day the project is done.
Thanks for allowing us to partner with you and your family
CONSENT TO WORK WITH US
In order for Good Neighbour to provide support to myself and my whanau, they may need to share my information with other agencies. I give consent for them to do so. All my information will be stored confidentially and shared in accordance with the Privacy Act 2020 and Good Neighbour volunteers.
Please tick if you understand the above and consent to this.
*
Name
Date
Thank you. Our Projects Team will be in touch with you soon.
Please check the highlighted fields
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