Get Involved with LIFT

Personal Information

Full Name

Date of Birth

Gender GenderMaleFemailGender Diverse

Ethnicity EthnicityMaoriNZ EuropeanPacificaOther

Address

Contact Phone Number

Email

Residential Status: NZ Citizen/Resident?

How did you hear about us?

Emergency Contact Full Name

Relationship

Emergency Contact Contact Number

Do you have any of the following Do you have any of the following Birth Certificate IRD Number Photo ID Bank Account Passport (NZ/Aus) 18+ Card Drivers License

Highest Educational Achievement Highest Educational Achievement No Qualifications Level 1 Certificate Level 2 Certificate Level 3 Certificate Level 4-6 Certificate Bachelor / Level 7

Do you have transport to get to work or training? Do you have transport to get to work or training? Own Car Bus Push Bike Family Member Other

What License do you hold? What License do you hold? No License Learners Restricted Full

Other means of transport

License Number

Would you like help getting or upgrading your license? Would you like help getting or upgrading your license?YesNo

HPR (Participant Engagement)

Have you ever been expelled or stood down from school, or asked to leave school? Have you ever been expelled or stood down from school, or asked to leave school? Yes No

Are you currently in eduction, training and/or employment Are you currently in eduction, training and/or employment Yes No

In the past 12 months, how many months have you NOT been in employment, education or training? In the past 12 months, how many months have you NOT been in employment, education or training?0123456789101112+

Are you currently receiving any type of WINZ support / MSD benefit? Are you currently receiving any type of WINZ support / MSD benefit? Yes No

WINZ Client #:

Do you have any children in your care? Do you have any children in your care? Yes No

Are you a sole parent?

How many children in your care?

Do you have any criminal convictions (or alleged convictions under investigations) at present? Do you have any criminal convictions (or alleged convictions under investigations) at present? Yes No

Please specify

How old were you when you last attended school?

Employment

What industries/areas would you like a job in? Preferred Jobs:

Do you want to own your own business? Do you want to own your own business? Yes No Maybe- I would like to know more about it

Where have you worked? Do you have any work experience/employment history? (Employment, work experience, volunteering etc.)

How many hours of work a week are you looking for? (If there are certain hours you can’t work please note them or note when you are available)

Do you or have you ever suffered from any medical conditions, injuries or disabilities that we need to know about to ensure your safety both at LIFT or in employment?

Would you pass a drug test if required? We can do confidential drug tests at LIFT to see if you are ready for employment Would you pass a drug test if required? We can do confidential drug tests at LIFT to see if you are ready for employment Yes No

Do you have any upcoming court appearances or probation requirements? LIFT may be able to support you with this Do you have any upcoming court appearances or probation requirements? LIFT may be able to support you with this Yes No

Court/Probation Dates

Who are your other support workers (Name and Contact details)?

Is there anything else we can help with?

Declaration

NOTE: Please acknowledge that we do not allow the use drugs or alcohol on the premises. Any persons processing, using or under the influence of drugs and alcohol will be asked to leave for the day. Participants must not where any identifiable gang affiliated clothing or regalia. Any persons with visible gang affiliated clothing or regalia will be asked to remove it or leave the office. *This information is required for enrolment Privacy Declaration I have been provided with the He Poutama Rangatahi Privacy Statement. I understand that the information I provide to LIFT Social Enterprise Limited is being provided voluntarily and for the purpose of providing me with a Ministry of Social Development (MSD) funded He Poutama Rangatahi service. If I choose not to provide the required information, I understand that I may be unable to participate in the Programme. My information will be held by LIFT Social Enterprise Limited and I understand that under the Privacy Act 2020 I have the right to access and correct any information that LIFT Social Enterprise Limited may hold about me. I agree that LIFT Social Enterprise Limited may contact schools, organisations or MSD on my behalf for the purpose of providing me with their services, and that those same schools/agencies/organisations may provide information that they hold about me for that same purpose. I agree that some of my information will be shared with Statistics NZ who will use the information in line with best practice. This information will be fed into the Integrated Data Infrastructure (IDI). Some of my information held by LIFT Social Enterprise Limited will be provided to MSD where this is required for the purposes of programme administration and the reporting of data. MSD may share information on my circumstances with LIFT Social Enterprise Limited to aid in eligibility determination and to enable programme service delivery. If I require further information about how MSD will manage my personal information, I understand that I am able to find this on MSD’s webpage under Privacy Notice. I understand I can withdraw from the programme in which I am enrolled at any stage by notifying LIFT Social Enterprise Limited and that some of my information will need to be retained for reporting purposes. I understand that I have a right to complain to the Privacy Commissioner if I am concerned about how my personal information is being used or protected by LIFT Social Enterprise Limited.

By ticking the circle below I confirm that the information I have provided is true and correct and that I have read and understand the privacy statement and declaration – See back of form for full privacy statement. LIFT may also use photos and/or videos of me to be used on social media and reporting. By ticking the circle below I confirm that the information I have provided is true and correct and that I have read and understand the privacy statement and declaration – See back of form for full privacy statement. LIFT may also use photos and/or videos of me to be used on social media and reporting. Applicant Sign Off (Tick)

Date: