COURSE YOU WISH TO ENROL IN
Start date of course / _ _ / _ _ / _ _ / Place / Town: Venue:
YOUR DETAILS
Mother’s First/Ingoa Name / Family/Whānau Name
NHI (contact your Midwife/GP if unknown) / Date of Birth / _ _ / _ _ / _ _ _ _
Ethnicity / Email address
Address/Kainga
Expect date of delivery (EDD) / _ _ / _ _ / _ _ / First baby /
  • Yes
/
  • No

Daytime contact phone / Mobile
Have you ever accessed a Pregnancy (Antenatal) or Parenting education before? /
  • Yes
/
  • No

Who will you be attending the course with?
Please tick: /
  • Partner
  • Husband
  • Friend
  • Other whānau support
  • On my own
/ Where did you learn about the course?
Please tick: /
  • Midwife / Lead Maternity Carer
  • General Practitioner (GP)
  • Social Worker
  • Internet
  • Other(please specify

Do you give your permission for us to contact you about a month after the course to ask you how useful it was for you? / I agree: /
  • Yes
/
  • No

PARTNER’S INFORMATION
First/Ingoa Name / Family/Whānau Name
NHI (contact your GP if unknown) / Date of Birth / _ _ / _ _ / _ _ _ _
Ethnicity / Email address
Address/Kainga
Daytime contact phone / Mobile

Plunket Privacy Statement

The information you provide in this form is being collected by the Royal NZ Plunket Society to enable you to participate in a free Pregnancy and Parenting Programme.The information you have provided may be used by the Royal NZ Plunket Society to inform the District Health Board for reporting and funding purposes of the course. Under the Privacy Act 1993 you have the right to have access to all information held about yourself, and to request correction of that information. To request access to, or correction of, any of your personal information collected for the above purposes, please contact:Plunket Privacy Officer,

Storage, access to, and correction of, your information:

  • Your own information is required to be accurate relevant, up-to-date and complete.
  • Plunket is required to protect your information against loss and unauthorised access, use, modification, or disclosure.
  • The information collected about you on this form, by facilitators during the course and during further follow-up parenting support will be stored in locked filing cabinets at Plunket premises. Information stored electronically is encrypted and password protected.
  • You have the right to access your own information at any time, but may be required to provide proof of identify. You do not have to give a reason for requesting this information.
  • You may ask for your information to be corrected if necessary, and you can expect Plunket staff to provide you with reasonable assistance in this regard. If it is not appropriate for the correction to be made, you may request a note to be attached to you information regarding your request.

The information you provide in this form is being collected by the Royal NZ Plunket Society to enable you to participate in a free Parenting Through Separation Programme. The information you have provided may be used by the Ministry of Justice and/or the Royal NZ Plunket Society for the purpose of determining your completion of the course, tracking the progress of your family dispute, providing and/or managing the out of court family justice services they may provide or fund, validating accuracy of information provided or for determining whether your family dispute can proceed to court.. Under the Privacy Act 1993 you have the right to have access to all information held about yourself, and to request correction of that information. To request access to, or correction of, any of your personal information collected for the above purposes, please contact:Privacy Officer, Ministry of Justice, SX 10088, WELLINGTON. Phone: 04 918 8800Email: privacy

1