Mercury Bay Blue Light – Youth Enrollment Form Download PDF Version Here Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Participant DetailsFull Name *FirstLastPreferred Name *Date of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender: *Ethnicity: *Please enter your ethnicity or ethnicities.Name of School *Address *Address Line 1CityState / Province / RegionPostal CodePhone *Email *Parent/Guardian InformationName *FirstLastPhone * & Information Address Email *Address (if different)Address Line 1CityState / Province / RegionPostal CodeEmergency ContactName *FirstLastRelationship *Phone *Medical & Support InformationDetails (allergies, conditions, support needs): *Doctor / Medical Centre: *Phone *Consents (Tick One)Participation *YesNoTransport: *YesNoPhoto/Media: *YesNoDeclaration of Authenticity and Consent By submitting this form, I declare that the information I have provided is true, accurate, and complete to the best of my knowledge. I confirm that I am the person named in this form, or that I have the proper authority to complete and submit this form on behalf of the person named. I understand that providing false, misleading, or incomplete information may affect my eligibility for support services, referrals, or assistance. I consent to Whitianga Community Services Trust collecting, using, and storing the information provided in this form for the purpose of assessing my needs, providing support, making appropriate referrals, and maintaining accurate service records. I understand that my information will be handled confidentially and only shared where necessary to provide support, meet legal obligations, protect safety, or where I have given consent. Agreement *I have read and understood this declaration of authenticity and consent.I confirm that I am not a robot and that this form is being submitted by a genuine person.Code of Behaviour AgreementI agree to follow the Mercury Bay Blue Light Code of Behaviour.Participant Signature: * Clear Signature Date: *Parent / Guardian ConsentI confirm the information is correct and consent to participation.Name *FirstLastParent Signature: * Clear Signature Date: *Office Use OnlyDate Received & Staff Member:Submit
