Child Details. Child’s official given name: Child’s official surname or family name: Child’s official other names/middle name: Name your child is known by/preferred name: Surname/Family Name: Given Name: Copy of official identity verification document* collected by staff: ❑ New Zealand birth certificate ❑ Foreign birth certificate ❑ New Zealand passport ❑ Foreign passport ❑ Other Staff Initials: Child’s date of birth: dd / mm / yyyy Male ❑ Female ❑ Ethnic origin: Iwi your child belongs to: Language/s spoken at home: Child’s primary residential address: Postcode Parents / Guardians: Are parents living together ❑ or separated ❑? First Name(MOTHER): First Name(FATHER): Surname: Surname: Address:❑ (Same as Child) Address:❑ (Same as Child) Post Code: Post Code: Ph (Work): Ph (Home): Ph (work): Ph (home): Ph (Mobile): Ph (Mobile): Email: Occupation: Email: Occupation: Emergency Contacts: People you would like us to contact if we are unable to contact you & are permitted to collect your child(ren) on your behalf What is this person’s relationship to your child, i.e. Grandmother, Uncle, Family Friend? What is this person’s relationship to your child, i.e. Grandmother, Uncle, Family Friend Eg. Aunt ...................................................................................... Eg. Grandmother ......................................................................................
Child Details. Legal Forename in full (no nicknames or middle names) Address and post code Legal Surname Name by which child is known if different to above Gender Male / Female Date of birth Proof of identity (birth certificate, passport etc) Extended entitlement code 2+ Authorisation Code Child’s ethnic group (please tick appropriate category from the choice below) White British WBR White/Black Caribbean MWBC Indian AIND White Irish WIRI White/Black African MWBA Pakistani APKN Traveller of Irish Heritage XXXX Xxxxx and Asian MWAS Bangladeshi ABAN Gypsy/Roma WROM Any other mixed background MOTH Any other Asian background AOTH Any other White background WOTH Black Caribbean BCRB Chinese CHNE Refuse to provide REFU Black African BAFR Any other background OOTH Info not obtained NOBT Any other Black background BOTH
Child Details. Child’s Surname (as on birth certificate) Child’s Forename(s) (as on birth certificate) Name by which the child is known (if different from above) Child’s Date of Birth D D M M Y Y Gender Documentary proof of DoB Type (eg. Birthcertificate, Passport): Document recorded by (name of staff member): Date document recorded (dd/mm/yyyy) 30 hour eligibility code (if applicable): (eg.12345678912) 2 year funding eligibility (E) number (if applicable): Address Postcode Child’s Ethnic Origin (please tick) White Asian or Asian British White British Indian White Irish Pakistani Traveller of Irish Heritage Bangladeshi Gypsy/Roma Other Asian Other White Black or Black British Mixed Black Caribbean White and Black Caribbean Black African White and Asian Other Black White and Black African Other Mixed Other Chinese Other Ethnic Group Sudanese
