PERSONAL INFORMATION *

First Name

Last Name

Phone *

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EMERGENCY CONTACT INFORMATION *

First Name

Last Name

Phone *

(###)

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PROGRAMS SELECTION

Select the program(s) you are interested in

Financial Mentoring

Financial Literacy

Parenting Program

Choice (Social & Emotional Well-being Program)

Learner Driver Licence

Te Maori Workshop

Craft-Making

Vege Garden

Consent and Agreement or Te Puna Waiora Programs *

DISCLOSURE STATEMENT: By submitting this form, you consent to the collection and use of your personal information for the purposes of program registration and management. Your information will be kept confidential and will only be accessible to authorized personnel. WAIVER STATEMENT: I acknowledge that participating in Te Puna Waiora programs may involve certain risks. I hereby release and discharge Te Puna Waiora, its officers, employees, and agents from any and all liability for personal injury, property damage, or wrongful death that may occur during my participation in these programs. TERMS AND CONDITIONS By registering for one or more Te Puna Waiora programs, you agree to adhere to the following terms and conditions: + Follow all instructions and guidelines provided by Te Puna Waiora. + Respect the privacy and confidentiality of all individuals you encounter. + Report any concerns or incidents to a program supervisor immediately. + Commit to the agreed-upon schedule and notify in advance if you are unable to attend. + Failure to comply with these terms may result in the termination of your participation in the programs.

I agree to the Disclosure, Waiver, and Terms & Conditions above.