HAUORA MAORI HEALTH WORKFORCE NEW ZEALAND (HWNZ) NON-REGULATED WORKFORCE TRAINING FUND 2017

CHECKLIST
USE THIS CHECKLIST TO ENSURE THAT YOU HAVE COMPLETED ALL SECTIONS OF THIS APPLICATION.
checklist
Number / Task / Page / Action / Yes / No
1 / Qualification sought must be Level2–7 / Pg. 3 / IDENTIFIED / YES / NO
2 / PriorityHealthWorkforceArea(s) / Pg. 3 / IDENTIFIED / YES / NO
3 / CourseisaNZQAqualification / - / CONFIRMED / YES / NO
4 / Papers full title or code / Pg. 4 / CONFIRMED / YES / NO
5 / ALLagreementsignaturesdates / Pg. 5, 9 / COMPLETED / YES / NO
6 / CareerPlan–2017 / Pg. 6 to 9 / COMPLETED / YES / NO
7 / MyPersonalCareerPlanReviewDate / Pg. 9 / COMPLETED / YES / NO
8 / CourseDescription / - / ATTACHED / YES / NO
9 / IMPORTANTCourseCostsorQuotes / - / ATTACHED / YES / NO
Send your completed application to including any documentation.

PERSONAL DETAILS
it is really important that you answer all questions 1 to 14. If a question does not apply to you please write na (non applicable)
  1. PERSONAL DETAILS
/ a. First Name:
b. Surname:
c. Date Of Birth:
d. employer name
e. Position Title:
f. Work Phone:
g. Home Phone:
h. Cellular (Mobile) Phone:
i. Email (Work or Home):
j. Total Hours Worked Per Week or FTE status:
K. total voluntary
hours:
  1. NEW ZEALAND PERMENANT
RESIDENT
(CIRCLE) / Yes / No
  1. ETHNICITY (CIRCLE)
/ NZ MĀORI / NEW ZEALAND EUROPEAN / PACIFIC / OTHER
  1. WHAKAPAPA
/ Iwi name(s)
Hapu name(s)
  1. LEVEL OF QUALIFICATION
/ CIRCLE (BELOW) THE LEVEL OF QUALIFICATION YOU ARE SEEKING FUDNING FOR
Certificate / Graduate certificate / Diploma
  1. PRIORITY HEALTH AREA
/ CIRCLE THE PRIORITY HEALTH WORKFORCE AREA YOU ARE SEEKING FUND FOR? FOR EXAMPLE, Health Care Assistance in Aged Care you would select Aged Care.
Aged care / Rehabilitation / Primary care


  1. SEMESTER ONE TRAINING INSTITUTE AND PAPERS PLANNED
/ COURSE INFORMATION SEMESTER ONE 2017
TRAINING INSTITUTE NAME / PAPERS FULL TITLE OR CODE / START DATE / FINISH DATE
  1. TRAVEL
/ WILLYOUNEEDTOTRAVELTOATTENDANYCLASSESASPARTOFTHESE PAPERS? / YES / NO
  1. DISTANCES
/ IF YOU DOHAVE TOTRAVEL, WHAT ARE THETOTAL KILOMETERSBETWEEN YOUR NORMALWORKPLACEANDYOURCLASS? / Number of km’s / TBC
  1. ACCOMMODATION
/ IF YES, HOW MANY DAYS/NIGHTS ACCOMMODATION DO YOU REQUIRE / Number of days/nights / TBC
  1. SEMESTER TWO TRAINING INSTITUTE AND PAPERS PLANNED
/ COURSE INFORMATION SEMESTER TWO2017
TRAINING INSTITUTE NAME / PAPERS FULL TITLE OR CODE / START DATE / FINISH DATE
  1. TRAVEL
/ Willyouneedtotraveltoattendanyclassesaspartofthese papers? / YES / NO
  1. DISTANCES
/ If you dohave totravel, what are thetotal kilometersbetween your normalworkplaceandyourclass? / Number of km’s / TBC
  1. ACCOMMODATION
/ IF YES, HOW MANY DAYS/NIGHTS ACCOMMODATION DO YOU REQUIRE / Number of days/nights / TBC


AGREEMENTSIGNATURES
(Please obtainALL relevantsignatures)
LINEMANAGER ‘AGREEMENT’ / IN SIGNING THIS APPLICATION, I CONFIRM THAT:
I have had a discussion with the applicant about their Professional Development and Career Plan and I support them in undertaking the above study and submitting this application for funding.
I have also considered the rostering implications particularly the needs of any ‘clinical’ areas and agree to release the trainee for the required amount of time to attend this course.
Name
DD/MM/YYYY
Signature / Date
0
APPLICANTS ‘AGREEMENT’ / INSIGNINGTHISAPPLICATION,ICONFIRMTHAT:
•Ihavecompletedboththechecklist(atfront)andtheapplicationinfull(allquestionsandpagescompleted)
IUNDERSTANDTHISDOESNOTGUARANTEEIWILLRECEIVEFUNDING
IACCEPTTHATIFIDORECEIVEFUNDING:
  • Itismyresponsibilitytoenrolinthecourse
  • I understand that accommodation and travel funding is a subsidy only and I am responsible for other costs e.g., kai
  • Iwillberequiredtoprovideevidenceoflearning
  • IfIwithdrawbeforecompletinganypartofthecourseIMAYBEREQUIREDTOPAYBACKTHEACQUIREDFUNDING
  • I understand cultural support is available e.g., mentoring
•Ihavenotappliedforanyotherfundingforthecourses above.
Name
DD/MM/YYYY
Signature / Date
CAREER PLAN 2017
PERSONAL DETAILS / FULL NAME
CURRENT POSITION
EMPLOYER ORGANISATIONNAME
DATE
PART 1: KNOW MYSELF / THE FIRST STEP IN PLANNING MY CAREER IS TO UNDERSTAND MY ASPIRATIONS KNOWING WHAT MY STRENGTHS, INTERESTS, DRIVERS AND OTHER INFLUENCES ARE?
The people or persons I have discussed my career with are? / MY MANAGER
MY KAUMATUA
MY CURRENT TUTOR
THE SUPERVISOR & MENTOR
A PROFESSIONAL LEADER
A PROFESSIONAL / CLINICAL SUPERVISOR
AN EDUCATOR
A CAREER DEVELOPMENT PROFESSIONAL
OTHER / 
PART 2: EXPLORE POSSIBILITIES / BASED ON MY ASPIRATIONS AND KEY STRENGTHS I HAVE DECIDED ON THE FOLLOWING CAREER PATHWAYS.
Career Pathway
Option One
Name it here / What are the pre-requisites and requirements to achieve Option 1:
Qualification
Previous Learning
Experience
Papers Other
(describe)
Career Pathway
Option Two
Name it here / What are the pre-requisites and requirements to achieve Option 1:
Qualification
Previous Learning
Experience
Papers Other
(describe)

HAUORA MAORI HEALTH WORKFORCE NEW ZEALAND (HWNZ) NON-REGULATED WORKFORCE TRAINING FUND 2017

PART 3: MAKE SOME CHOICES / KNOWING MY POTENTIAL I HAVE SET THE FOLLOWING GOALS TO SUCCESFULLY COMPLETE MY TRAINING.
GOAL ONE
What I need to be able to do to achieve Goal One?
GOAL TWO
What I need to be able to do to achieve Goal TWO?

PART FOUR: MAKE IT HAPPEN / INORDERTOACHIEVEMYGOALS:
1.Ineedanagreedcourseofaction
2.MymanagerandIneedaclearunderstandingofwhatstepstotake,thecommitment neededbybothofusandtherelevanttimeframes.
MypersonalCareerPlanislaidoutbelow,foryourconsideration.
MY CAREER PERSONAL PLAN
START
DATE / FINISH
DATE / SKILL/KNOWLEDGE TOBE GAINED / HOWWILLTHISBEGAINED?E.g. on the job, study. / TYPE OF TERTIARY PROVIDERe.g.Wananga; Kuratini; University; Polytech.
DATE OF YOUR REVIEW / DD/MM/YYYY
LINE MANAGER SIGNATURE / NAME OF ORGANISATION
DATE SIGNED / DD/MM/YYYY