Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Non Binary
Prefer not to say
Ethnicity ( Tick all that apply )
*
If Maori, Please State Your Iwi
Phone
(###)
###
####
Email
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name
*
First Name
Last Name
Emergency Contacts Phone
*
(###)
###
####
Are you attending as
*
What challenges or barriers are you currently facing in achieving your goals? (Select all that apply)
*
What specific goals or outcomes do you hope to achieve through participation? (Select all that apply)
*
Do you have any medical conditions, disabilities, or other needs we should be aware of?
*
No
If yes, please specify;
Please tell us your medical conditions, disabilities, or other needs;
Do you have any dietary restrictions or allergies?
*
No
If yes, please specify
Please tell us your dietary restrictions or allergies;
Are you comfortable participating in physical activities?
*
Yes
If no, please specify any limitations:
Your limitations participating in physical activities?
Participation Commitment - Can you commit to attend 2 of the noho wānanga series?
*
This programme follows a holistic approach, with each wānanga building upon the previous one to create a journey of personal, cultural, and relational growth. Full attendance is vital for participants to benefit from the entire experience.
Do you have reliable transport to attend the wānanga?
*
Yes
No
If no, would you need support with transport?
Additional Support and Accessibility Needs - Do you need support with child care while attending the wānanga?
*
Children are unable to attend the wānanga to ensure participants can fully engage with the experience.
Do you have any other needs that would help you fully engage in the wānanga?
How did you hear about the Mura Noho Wānanga series?
*
Word of mouth
Social media
Community group
Other
Would you be willing to provide feedback during or after the wānanga series?
*
Yes
No
Do you give permission for your photos, videos, or feedback to be used for programme promotion?
*
Yes
No
Do you agree to respect the shared kaupapa of the programme and uphold tikanga during the wānanga?
*
Yes
No
Do you speak or have an interest in learning Te Reo Māori?
*
Do you attend the gym, participate in physical activities, or have an interest in attending group fitness classes?
*
Do you have supportive network of peers, or are you seeking to form these?
On a scale of 1 - 10 how confident are you in the water
*
Would you pass a 100 metre swim test
A safety debrief phone call will be made once you submit
For the purpose of fitting you out with dive equipment. What is your
Height
Weight
Shoe size
