Te Oriori Referral Form Te Oriori Referral Form Referral Type:* Self referral Whanau member referral Agency/Professional referral Referrer Name First Last Contact NumberEmail Agency Name (if applicable)Please state your relationship to the person you are making the referral for:Parent/Caregiver DetailsParent/Caregiver Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity/IwiNHI (only if known)Gender Female Male Other Contact DetailsAddress Street Address Address Line 2 ZIP / Postal Code Contact Number*Email GP / Medical CentreTamariki DetailsComplete for children who will attend Te Oriori programmesChild 1 Name First Last Date of Birth Date Format: DD slash MM slash YYYY Ethnicity / IwiGender Male Female Child 2 Name First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity / IwiGender Male Female Child 3 Name First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity / IwiGender Male Female Child 4 Name First Last Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity / IwiGender Male Female Emergency ContactName First Last Contact NumberRelationship e.g. Partner, mother etc.Please select the programme(s) you are interested in attending Whare Takaro (Wednesday Play Group) Mana Reo (Thursday Te Reo Maori class) Awesome Whanau (Friday Parenting Course) Consent I give my consent that information may be shared with other staff of Purapura Whetu for the purposes of my participation in Te Oriori if required.Photographs I agree that any photographs, videos taken during the activities may be used for promotional purposes in connection with future activities similar to these including on the website and in advertising material.
