Enrol with Whanake House — Whanake House

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Dairy Farm Training Programme

Dairy Farm Training Programme

Dairy Farm Training Programme

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Enrol with Whanake House

Fill out the form below to apply to enrol with Whanake House.

Your completed form will be sent to the Transition Coordinator and contact will be made with you to discuss the next steps.

Client Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Email *

Contact Number (of above name) *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Diagnosis *

Main Contact Person & Number (for training & updates to be sent) *

Emergency Contact Person & Number *

Support Needed *

Strengths *

Cultural/Religious Considerations

Dietary Requirements *

Services of Interest

Frontline Training

Rural Dairy Farming

Social Group

Personal Training

Living Skills/Life Skills

Driver License (Learners/Restricted/Full)

Which Best Describes your Nationality? (tick one only)

New Zealand

Māori

NZ European

Pasifika

Asian

Other

Which ethnic group do you belong to?

Iwi Affiliation

If you identified as Māori, what is the name of your iwi? If unknown, please put "unsure"

Whanau Volunteers

Permission to be Transported by Whanake House Staff

Yes

No

Water Competence

For activities on, in or around water (please tick all those that apply)

I am a non-swimmer (unable to float or move myself through water)

I am a confident swimmer and can competently swim 25 meters

I can confidently and competently swim 50 meters

I can confidently and competently swim 200+ meters

I am confident in deep water

I am able to tread water for 2-3 minutes

I am able to survival float on my back for 2-3 minutes

I am safety conscious in and around water

Medical Information *

I give permission for this information to be shared with the Whanake House staff in charge if required:

Yes

No

Medical Conditions *

Severe Migraine

Diabetes

Chronic Nose Bleeds

Epilepsy

Travel Sickness

Heart Condition

Anaphylaxis

Asthma

Dizzy Spells

Seizures of Any Type

Visual Impairment/Concerns

Mobility Issues

Hearing Impairment/Issues

Intellectual Disability

Other (please note below)

Medical Conditions

If you selected "Other" or would like to discuss further, please note below.

Allergies

Please note any allergies below

Are There Any Safety Concerns we Should be Aware of?

(i.e., Flight Risk, Aggressions etc). If yes, is there a safety plan in place?

Parent/Caregiver Consent

If you are filling this out on behalf of the applicant, please tick the boxes below to complete the Parent/Caregiver consent:

I give the applicant permission to participate in Whanake House activities

The applicant has read and understands the Whanake House Code of Conduct

The applicant's medical information is up-to-date with Whanake House

The applicant acknowledges and accepts the Risks Disclosure (see below)

Applicant Consent

If you are filling this out for yourself, please tick the boxes below to give consent:

I consent to participate in Whanake House activities

I have read and understand the Whanake House Code of Conduct

My medical information is up-to-date with Whanake House

I acknowledge and accept the Risks Disclosure (see below)

Thank you!

Risk Disclosure - Please read before accepting.
Code of Conduct - Please read before accepting.

Goal-based transition for Southland’s young people with high-functioning disabilities into work opportunities, community placements and tertiary education.

494 Dee Street, Gladstone, Invercargill

Ph: 027 620 9867

Terms and Conditions