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Parent/Caregiver Name
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Child's First Name
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Child's Last Name
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Doctor's Name
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Medical Centre - Please select from the list
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Unit/Apartment
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Street Number & Name
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Suburb
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Town/City
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Postcode
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Sport Waikato District
Hamilton
Hauraki
Matamata Piako
Otorohanga
South Waikato
Taumarunui
Taupo
Thames Coromandel
Waikato
Waipa
Waitomo
Other
Home Phone
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Mobile Phone
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Business Phone
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Email Address
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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)
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Gender
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Gender
Male
Gender
Female
Gender
Other, see notes
Ethnicity
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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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