Kidzacool Referral - Return Stay

KidzaCool Adventures - Return Stay Application
Which holiday programme date and location do you wish your tamariki mokopuna (child) to attend?
Child and Caregiver Details
Referral Type
Child Ingoa Name

First NameMiddle NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearNote child must be between 5 and 12 years of age
NSN (National Student Number)
NHI (National Health Index)
Primary Address tamariki mokopuna (child) lives at:

Street Address

Suburb or RD

City or TownState / Province

Post CodeCountry
Caregiver contact details are:

First NameMiddle NameLast Name
Relationship to Child
Home Phone

Area CodePhone Number
Mobile Number

Area CodePhone Number
Caregiver's email address:

Confirmation Emailexample@example.com
Is it OK to use this email address for communications and notifications?
Are there any Court Orders in force for custody/access? (If yes, a copy of court orders must accompany this referral)
Tamariki mokopuna (child) has lived with current caregiver(s) since:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
How many tamariki mokopuna (child)ren live with caregiver?
Do you have legal custody/guardianship for the child?
If no, name of person who has legal custody/guardianship for the child
Are you a referring agent?
Referral agent name

First NameLast Name
Agency Role
Agency
Referral agent number

Area CodePhone Number
Referral agent email

Confirmation EmailA copy of the filled form will be sent to this address so please enter twice to confirm accuracy
Agency Address

Street Address

Street Address Line 2

CityState / Province

Post Code

Details of all people living at child’s address

Please include other children and note if the person is a Legal Guardian
Emergency Contact Name:

First NameLast Name
Relationship to child: e.g. Nan/Koro/Friend
Preferred Contact Method:

Area CodePhone Number

Tamariki mokopuna lives with (including all other children):

Rows	Full Name	Relationship to child: e.g. nan/aunty/koro/siblings	Legal Guardian Yes/No	Gender
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9
Person 10

At the moment, these are the people they cannot have contact with:

Rows	Full Name	Relationship to child:e.g. mum/dad/siblings	Legal Guardian Yes/No	Gender
Person 1
Person 2

Reason(s) the above people are not able to have access right now:
If the legal guardian does not live at the child’s address, please provide the contact details of all legal guardians as we are required to advise all legal guardians of our service involvement.

Legal Guardian(s) not living at child's address

Rows	Name of Guardian	Relationship to the child: e.g. mum/dad	Preferred Contact Method:
Person 1
Person 2

General Information
To help us support your tamariki mokopuna (child), please fill out the prompts to let us know what might be challenging for them, what triggers big feelings, and what helps when things feel hard.
Things that might trigger them to lose control or have big feelings are:
In response to these, some of the behaviours that might be shown are:
Calming and support strategies - what helps them:
Is there any other information that you would like us to know about your tamariki mokopuna (child)?
If tamariki mokopuna (children) are placed in groups - is there a friend or sibling attending that your tamariki mokopuna (child) would like to be grouped or not grouped with (if possible)?
Due to illness or changes in plans, some may choose to cancel or defer their attendance. We want to make sure those who are on the waitlist can have an opportunity to attend if available. Would you be available to bring your tamariki mokopuna (child) at short notice should a place become available? If so, what is the best contact number?
What is the best contact number we should use to advise you if a place becomes available?
What travel arrangements have you made to bring your tamariki mokopuna (child)ren to KidzaCool Adventures (Note: If you require assistance with travel, please contact us to discuss)

Please click PREVIEW to check your form and SUBMIT only when you have completed the form - you will not be able to edit it once it has been submitted.
Should be Empty:

Rows	Medication name	What I take it for e.g. Asthma	Dose (How much I need)	Dosage (When I need it)
1
2
3
4
5

Rows	Medication name	What I take it for e.g. Anxiety Disorder	Dose (How much I need)	Dosage (When I need it)
1
2
3
4
5

Rows	Medication Name	What I take it for e.g. Autism Spectrum Disorder	Dose (How much I need)	Dosage (When I need it)
1
2
3
4
5

Rows	Allergy	Cause	Effect	Treatment Required e.g. epi pen
1
2
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5

Rows	Medication	What For	Dosage	How Often
1
2
3
4
5

KidzaCool Adventures - Return Stay Application

Child and Caregiver Details

Details of all people living at child’s address

Health Information

Community Services Card Details

Consent to Administer Medications and Seek Medical Treatment

Current Behaviour Checklist - Part 1

Current Behaviour Checklist - Part 2

General Information

Consent for Kidzacool Adventure Programme

Consent for Participation in Higher-Risk Activities

Rows	Anything we need to be aware of:	N/A
Biking/scooters
Boating
Camping overnight (away from site)
Horse Riding
Kayaking/Canoeing
Marae Visits (sleepover)
Rollerblades/skateboarding
Swimming (pools, beaches, lakes & rivers)