Manawa Hou 2015 -Consent Form-2

Manawa Hou Enrolment and Consent Form
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Please return these forms to manawa.hou@ngaitahu.iwi.nz before April 9 , 2015
RAKATAHI DETAILS Te kaitono
Full name
Gender
Male
Date of birth
/
Year at school
Yr 11
Ethnicity
Māori
Kāi Tahu
Tick here if you are registered with Kāi Tahu
Female
/
Age
Yr 12
Yr 13
NZ European/Pakeha
Other - state:
Iwi affiliations
Kāi Tahu
Rūnaka
affiliations
Arowhenua
Kaikōura
Makaawhio
Ōraka Aparima
Ngāti Waewae
Waihao
Postal address
Home phone
Work
Mobile phone
Fax
Email
School/Education
Favourite
Subjects
Interests &
Hobbies
Career
Aspirations
Awarua
Kāti Huirapa ki Puketeraki
Moeraki
Ōtākou
Ngāti Wheke
Waihōpai
Hokonui
Koukourārata
Ōnuku
Ngāi Tūāhuriri
Te Taumutu
Wairewa
2.
NEXT OF KIN/ EMERGENCY CONTACT DETAILS Te whānauka tata
Parent/Caregiver Name
Full name
Postal address
Home phone
Mobile phone
Work
h
Fax
Email
Alternative email
Emergency Contact 2
Full name
Postal address
Home phone
Mobile phone
Work
h
Fax
Email
Alternative email
3.
PERSONAL HISTORY Mō te kaitono
CULTURAL KNOWLEDGE Te taha ahurea
To help us plan your course - rate your knowledge of the following cultural practices
knowledge
Excellent
Very good
Reasonable
Limited
No
Mahika kai food gathering
Pūrākau history/tradition
Tikaka/Kawa customs/protocols
Waka traditional canoes
Kapa haka performing arts
Te Reo language
4.
RAKATAHI LETTER OF APPLICATION
Please tell us why you’d like to register for Manawa Hou and what you hope to get out of the opportunity.
5.
MEDICAL INFORMATION Te taha rokoā
Please tick if you/your child suffers from any of the following:
Blackouts
Asthma
Sleep walking
Migraine
Diabetes
Back problems
Car sickness
Fits
Dizzy spells
Sea Sickness
Fear of heights
Heart condition
Fear of open spaces
Please outline any allergies:
Please specify any current/past injuries, or any medical condition, that may affect course participation:
Does your son/daughter receive any medication? Please tick.
Yes
No
If yes, please specify:
Does your son/daughter usually administer the medication themselves?
6.
Yes
No
SPECIFIC REQUIREMENTS Kā hiahiataka motuhake
DIETARY Te kai
N/A
Gluten free
-------------------5 -----------------okay
Relates to other rakatahi
1---------------- --------------------5 -----------------Doesn’t feel confident
okay
communicating
with other rakatahi
----------------10
Very fit
----------------10
Communicates with other rakatahi
WATER CONFIDENCE Kauhoe
Are you confident in water, can swim at least 50metres and are comfortable putting your head underwater?
NO
YES
All rakatahi MUST be able to swim at least 50 metres
SMOKEFREE Auahi kore
Do you smoke?
YES
NO
If YES - how many do you smoke a day
N/A
YES
NO
Vegan
Other food allergies/intolerances - provide details of food types, severity & last
Vegetarian exclusive
reaction:
Fitness
1---------------Unfit
Dairy free
and are you willing to be smokefree on Manawa Hou?
6
PERMISSION FORM / ACKNOWLEDGEMENT OF RISK -Te whakaaetaka/ te mōhio ki kā mōrearea
I approve of my son/daughter,
to go on Manawa Hou in Ngāti Waewae from 14-17 April 2015. I
agree that he/she should take part in such activities and duties that may be required by staff. I have read the
accompanying information and satisfied that my son/daughter will comply. If medical assistance is required I
authorise such action to be taken as thought necessary by staff. I understand that if my son/daughter is sent home
due to misbehaviour I will be required to meet the costs of the transport involved. I also give permission for photos of
my son/daughter to be used for presentational and promotional purposes.
My son/daughter is meets all the criteria, including being able to swim at least 50 meters.
Signed
7.
Date
_______
RAKATAHI DECLARATION Te whakapuakika
I agree to comply with the kaupapa of Manawa Hou and in particular I will follow all instructions and act with common
sense, safety and consideration for others.
Signature
Rakatahi
Date
What next?
Please return these forms via email to: manawa.hou@ngaitahu.iwi.nz or by post to Manawa Hou, Te Rūnanga o Ngāi
Tahu, PO Box 13046, Christchurch, 8141 before April 9, 2015.