Your Details
Parent/Caregiver Name
Child's First Name
Child's Last Name
Doctor's Name
Medical Centre - Please select from the list
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Unit/Apartment
Street Number & Name
Suburb
Town/City
Postcode
Sport Waikato District
Hamilton
Hauraki
Matamata Piako
Otorohanga
South Waikato
Taumarunui
Taupo
Thames Coromandel
Waikato
Waipa
Waitomo
Other
Home Phone
Mobile Phone
Business Phone
Email Address
Preferred Contact Method
Any
Email
Home Phone
Mail
Mobile Phone
Txt
Contact Time
Any
Morning
Afternoon
Evening
Child's Date of Birth (DD/MM/YYYY)
Gender
Gender
Male
Gender
Female
Ethnicity
African
British
Chinese
Cook Island Maori
European
Fijian
Fijian Indian
Indian
Japanese
Korean
Maaori
Middle Eastern
New Zealand European
Niuean
Non-Maaori
Samoan
South African
South and Central American/ Latin American
Tokelauan
Tongan
Other Asian
Other Ethnicity
Other European
Other Pacific Peoples
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