Registration FormFill out this form if you are registering for yourself or a friend / whanau Name * First Name Last Name Date of birth * Please enter as dd/mm/yyyy Gender * Please select an option below Female Male Gender diverse I prefer not to say Pronoun * He/Him She/Her They/Them Other Pronoun if checked 'Other' above Ethnicity * New Zealand Māori New Zealand European Other European Samoan Cook Island Māori Tongan Niuean Tokelauan Fijian Asian Pacific Peoples Asian Southeast Asian Chinese Indian Other Asian Middle Eastern Latin Amercian African I prefer not to say I don't know Other Iwi Secondary Iwi NHI number (found on a prescription, test result or your online patient portal) Full physical address * Please include street, suburb and post code Phone * Email Medical Centre * Name of GP * Health Conditions * High blood pressure High cholesterol Prediabetes Type 2 diabetes Depression Anxiety None of the above Factors affecting your participation in class E.g. use a walker, low vision, etc. Please list any special dietary requirements or food allergies e.g. gluten free, vegetarian, etc How did you hear about our programme * Thank you!
