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 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!
