HPR FORM | Rāngai

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RĀNGAI ENGAGEMENT FORM

Gender *

Female

Male

Gender diverse

Prefer no to say

Ethnicity * Required

Māori

NZ European

Pacific Islander

Other

Prefer not to say

Iwi (please print clearly):

Date of Birth * required

Residency Status *

New Zealand Citizen

New Zealand Resident

Other

Highest Qualification Achieved *

None

NCEA Level 1

NCEA Level 2

NCEA Level 3

NCEA Level 4-6

NCEA Level 7+

Before participating in this programme, what were you doing? *

Not in Employment, Education or Training

in Employment

in Education

in Training

In the past 12 months how many months have you NOT been in employment education or training *

Are you currently recieving any type of WINZ support / MSD Benefit ? *

Yes

if 'Yes', please provide your MSD client number

Current Drivers Licence *

None

Learners Licence

Restricted Licence

Full Licence

Do you have any criminal convictions ? *

Yes

Have you or are you currently involved in the justice system? *

Yes

Prefer not to say

If you have depandents, how many people are dependant on you? (please enter "0" if you don't have any dependents)

Do you have a health condition or disability that has been a barrier to employment? *

Yes

Prefer not to say

Are you a sole parent? *

Yes

How old were you when you last attended school

Have you ever experienced expulsions or stand-downs from school, or been excluded from school? *

Yes

Rāngai is funded by the Ministry of Social Development (MSD). As part of our funding agreement, we are required to provide anonymous demographic data about participants in our programmes to MSD. The data is used for monitoring and research purposes.

I consent to the information above being shared with the Ministry of Social Development.

I understand that my name, or any other personally identifiable information, will not be shared.

First Name

Middle Name(s)

Last Name

Signature

Parent/guardian if under 18)

Rāngai Policy

info@rangai.nz

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