HPR Form

Rāngai Engagement Form

This information supports our reporting to funding partners. Please answer honestly. It never affects your acceptance.

First Name *

Middle Name(s)

Last Name *

Gender *

Female Male Gender diverse Prefer not to say

Ethnicity *

Māori NZ European Pacific Islander Other Prefer not to say

Iwi Please print clearly

Date of Birth *

Residency Status *

NZ Citizen NZ Resident Other

Highest Qualification Achieved *

None NCEA Level 1 NCEA Level 2 NCEA Level 3 Level 4 Level 5 Level 6 Level 7+

Before participating, what were you doing? *

Not in Employment, Education or Training In Employment In Education In Training

In the past 12 months, how many months were you NOT in employment, education or training? *

Are you currently receiving WINZ/MSD support? *

Yes No

MSD client number (if yes)

Current Drivers Licence *

None Learners Restricted Full

Do you have any criminal convictions? *

Yes No

Are you involved in the justice system? *

Yes No Prefer not to say

How many dependents do you have? Enter '0' if you don't have any

Do you have a health condition or disability that is a barrier? *

Yes No Prefer not to say

Are you a sole parent? *

Yes No

What age were you when you last attended school?

Any school expulsions, stand-downs or exclusions? *

Yes No

I consent to the information above being shared with MSD. *

Signature (type your full legal name) *

Parent/guardian (if under 18)