Has your child previously attended a KidzaCool programme?
If Yes, use the KidzaCool Child Details Update Form to inform us on current details.
If No, please complete this form
Which camp date and location do you wish your child to attend?
Child and Caregiver Details
Name of child Male Female Date of birth
Physical Address Ethnicity:
NZ Maori NZ European
Street Indian Cook Is
Post Code Samoan Other Pacific
South East Not known
Other Asian Other
Present caregiver(s) Iwi
Name Relationship to Child Your Age Group
Alternative Contact Person for
Please select your age group from the following: 18-30, 31-44, 45-
59, 60-69, 69-79, 80+ (this is required for reporting purposes) Telephone
Child has lived with current caregiver(s) since Do you belong to
Date ……………/………………/…………… Grandchildren
How many children live with caregiver
Fostering Kids (NZ Foster
Do you have legal custody / guardianship Yes / No Care Federation)
If no, name of person who has legal custody/guardianship for child
Other caregiver support group
Are you receiving a Home for Life support package? Yes No Please specify
Are you being supported by a referring agency or community (Office Use Only)
service? Date Received
Date Referral entered on Freedom
Individual File Number
November 2011 Page 2 of 6
Behaviour and Health Checklist
The following behaviours are indicators for us of the level of support your child will need.
Please tick in the boxes all of those behaviours that apply to your child.
Does your child often: No Yes No per Has your child: No Yes No of
Lose his/her temper? Run away from home?
Argue with adults? Run away from school?
Defy or refuse adult Broken into someone’s
requests or rules? house or car?
Deliberately do things to Deliberately destroyed
annoy people? other’s property?
Blame others for own Deliberately destroyed
mistakes? their own property?
Get touchy or easily Been physically cruel to
annoyed by others? animals?
Seem angry and resentful? Been physically cruel to
Act spitefully or Used a weapon in more
vindictively? than one fight?
Swear or use obscene Deliberately set fires?
Skip school? Displayed sexualized
Initiate physical fights?
Office use only: Risk Assessment: High Medium High Medium Medium Low Low
Is the child diagnosed as having any of the following conditions?
Physical: Mental Developmental
Enuresis ADD / ADHD Learning disability
Encopresis Oppositional Defiance Disorder Intellectual disability
Asthma Conduct disorder Sensory disability
Epilepsy Anxiety disorder Aspergers
Hearing problems Eating disorder Autism
Vision problems Mood disorder Other
Skin problems Phobic disorder Pls state ___________
Obesity Pls state__________________
Pls state ___________
November 2011 Page 3 of 6
Child’s Name ______________________________
Any recent or current ill health
Any special health needs we should be aware of
Does the child suffer from any allergies e.g. food, bites, stings or medications?
Is the child currently taking any medication? YES NO
Medication What for Dosage How Often
Has the child had contact recently (within the last three months) with any infectious diseases e.g. Mumps,
Measles, Chicken Pox? YES NO
If YES please specify what disease: ____________________________ When ______________
Please indicate which of the following immunisations the child has received (please circle)
Diptheria Tetanus Whooping cough Polio Hepb Influenzae type b
Pneumococcal Measles Mumps Rubella
Name of Family Doctor (GP)
Community Services Card Details
This is required should the child need medical care/prescriptions while at camp.
Community Services Card YES NO Is your child covered YES NO
Card Number (16 Digit Number) 00000/_ _ _ _ /_ _ _ _ /_ _ _
Group Number (Please Circle) 1 - 2 - 3 Expiry
N.H.I. number (National Health Number)
November 2011 Page 4 of 6
Child’s Name ______________________________
Your child will be with us for five days, what is one thing that you would like to see your child achieve?
Is there any other information that you would like us to know about your child?
What is one thing you would like to achieve from having a break?
Children are placed in groups - is there a friend or sibling attending that your child would like to be
grouped or not grouped with?
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
send your child at short notice should a place become available? (circle one)
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 children to camp?
Note: If you require assistance with travel please contact us to discuss.
November 2011 Page 5 of 6
Name of Child ______________________________________
I agree to my child attending Te Puna Whaiora KidzaCool Adventures Camp. YES NO
I understand that the Te Puna Whaiora Staff will take all reasonable steps to safeguard YES NO
my child’s personal property while in camp. However, the Camp and Staff will not be
held responsible for any accidental loss or damage to my child’s personal property.
I give my consent for the Te Puna Whaiora to
Arrange necessary medical assessment and/or treatment for my child while in Holiday YES NO
Give medications necessary for general health care of my child while in Holiday Camp YES NO
Authorise emergency medical or surgical treatment for my child should the need arise YES NO
I give permission:
For the Te Puna Whaiora to OBTAIN and RELEASE relevant information to the YES NO
referring agent which will assist any follow-up of the child required.
For the Te Puna Whaiora staff to document daily observations for the purpose of an YES NO
activity report for the caregiver of the child’s stay.
For my child to participate in appropriate programmes and activities offered at the YES NO
KidzaCool Adventures camp.
I give permission for my child to participate in the following:
Boating YES NO Marae visits (sleepover YES NO
Canoe/Kayak YES NO Swimming YES NO
Van trips YES NO YES NO
I give my consent for:
My child and myself participating in a KidzaCool Adventures Programme evaluation for YES NO
the purpose of improving service delivery.
Our child and family information being used (without identifying my child or my family) YES NO
for the purpose of reviewing holiday camp services.
My child’s photograph and name being used for publicity purposes if it arises. YES NO
Are there any Court Orders in force for custody / access? YES NO
(If Yes a copy of court orders must accompany this referral)
Is there any person(s) you do not wish to visit your child during their stay?
If you do not have custody or guardianship, then the legal guardian must also sign this consent form.
Signature Signature Date
Signature of Caregiver(s)
Signature of Legal Guardian
November 2011 Page 6 of 6