Completed forms can be emailed or sent to:

Carol Wood
Email /
SUPPORT SERVICE NAME
Description of Support Service
(150 words max)
PHYSICAL ADDRESS
Building
Street
Suburb
Town
Postcode
POSTAL ADDRESS (if different from above)
P O Box/Bag Number
Suburb
Town
Postcode
Which addresses should be viewable to the public? Display Physical Address Display Postal Address
REGIONS
Please highlight below the regions that you would like to be considered for:
Northland / Tairawhiti – Gisborne / Wairarapa / West Coast
Waitemata / Lakes – Rotorua / Hutt Valley / Otago
Auckland / Hawke’s Bay / Capital & Coast – Wellington / Southland
Counties Manukau / Taranaki / Nelson Marlborough / National
Waikato / Whanganui / Canterbury / International
Bay of Plenty / MidCentral –Palm Nth / South Canterbury
CONTACT DETAILS
Phone
Fax
Free Phone
Cell Phone
Email
Website

Please tick the appropriate boxes below that apply to the types of services that your company provides. This will ensure your company details are displayed under the correct categories.

DISABILITIES
Spinal Cord Injury
Arthritis & Rheumatology
Respiratory Conditions
Neurological
Cardiac Conditions
Autoimmune Conditions
Intellectual Disabilities / Visual Impairment
Hearing Impairment
Deaf
Blind
Muscular &
Neuromuscular Conditions / Mental Health
Continence
Rare Disorders
Intellectual and Learning Disorders
Speech and Language
Amputees
REHABILITATION
Heath Professionals
District Health Board
Needs Assessment/Service Coordination / ACC
Care Agencies
Hospice
Medical Search Engines / Primary Health Organisations
Ministry of Health
Rest Home
Other
LIVING
Independent Living
Working Dogs
Travel / Relationships
Experiences
Parenting / Recreation
Sport
HOUSING
Design
Support / Resources
Government Agencies / Rights
EMPLOYMENT
Support / Rights / Government Agencies
TRAVELLING
Support
Rights
Public Transport / Accessible Taxis
Other transport Options
Vehicles / Holiday in New Zealand
Holiday in Australia
Overseas
SUPPORT
Advocacy Services
Support Groups
Research &Publications
Equipment Repair / Government Agencies
Rights
Standards
Statistics / Research
Opinion
Funding
EDUCATION
Support
Rights
Other / Preschool
School / Tertiary
Government Agencies
ENAW403 – WEKA Support Services Form
14/10/2015 / © Enable New Zealand, 69 Malden Street, PO Box 4547, Palmerston North 4414 / Page 1 of 2