Mana Kidz - Family/Whānau Information & Consent Form

Mana Kids Consent Form

This consent form tells us whether you want or do not want your child to have health checks at school. Important information: 

 

Please read the introduction document above and indicate here that you have done so before you fill this form out.

Yes I have red the introduction.

Section A: CHILD'S DETAILS

All parents/guardians must fill out this section

Gender *

Male Female

Date of Birth *

* An NHI (National Health Index) number is a unique number assigned to each person who accesses publicly funded health servies in New Zealand.

Which ethnic group does your child most closely identify with? (you may choose more than one)

NZ European Māori Samoan Cook Island Māori Tongan Niuean Chinese Indian Other - state in next field what this is.

You must fill in either Section B    OR    Section C

Section B: YES (agree) - I DO want my child to have health checks at school

Yes, I agree to my child having health checks at school

YES

I am (please chose one)

Mother Father Guardian

Adding your name below is equivalent to signing this section of this document.

Date Signed

Section C: NO (do not agree) - I DO NOT want my child to have the health checks at school

No I do not want my child having health checks at school.

NO

I am (please choose one)

Mother Father Guardian

Adding your name below is equivalent to signing this section of this document.

Date Signed