Contact Us

First Name

First

Last Name

Last

MSD Client Number (If you have one)

Gender

Email

Date of Birth

Ethnicity

Residence at Birth

Mobile

How did you hear about us?

Have you or your family previously received support from any of our services?

Yes

No

What was the services that you received?

What is your query about?

Drivers Licence

Whanau Resilience

Whanau Ora

OtherOther

Address

Suburb

City

Province

Zip Code

Message

Referral Information

Name of referrer

Agency Name

Referrer Phone/Mobile

Referrer Email

Reason for Referral

Other agencies involved, if any

Your safety

Do you feel safe?

Yes

No

Do you need advocacy & support?

Yes

No

Is there a police safety order?

Yes

No

Is this an urgent request?

Yes

No

Are there bail conditions?

Yes

No

Is there a parenting order?

Yes

No

Additional Information: Example: Bail conditions/ police orders / partner-ex partner already involved in Kainga Pasifika Services

Emergency Contact

Emergency Contact Person Name

Emergency Contact Person Phone

Relationship

Eligibility

Are you a MSD client?

Yes

No

Residency Status

NZ Citizen

Permanent Resident

Working Visa

Other (please specify)Other (please specify)

Occupation

Are you high school student enrolled in a school and are you registered as 500 or above in the equity index?

Yes

No

Not applicable

I meet the income test for this programme

Yes

No

Not applicable

Licence

Which licence are you applying for?

Learners

Restricted

Full

How confident are you driving a vehicle?

No experience

Little experience

Some experience

Confident

Transport

I require transport from the driving instructor to attend the restricted/full licence practice lessons.

Yes

No

Dates of Programme

Time of Programme

Pick up location

Suburb

City

Province

Zip Code

Drop off location

Suburb

City

Province

Zip Code

Contact Preferences

Preferred contact method

Phone

Email

Best time to be contacted

I confirm that the information I have provided is true and correct and that I have read and understood it in compliance with the Privacy act 2020.

Signature

Clear

I give permission for my photo to be taken and used by Kainga Pasifika Services Trust for evidential purposes.

Signature

Clear

I give permission for my photo to be taken and used on the Kainga Pasifika Services trust social media and website.

Signature

Clear

Captcha

Referral Information

Your safety

Emergency Contact

Eligibility

Licence

Transport

Contact Preferences

Get in touch