Robots Programme Application Form
Referrer Details
Select You Referrer Type
Please select...
Professional or Educator Referrer
A Whanau member or Friend
First Name
Your First Name
Last Name
Your Last Name
Email Address
Your Email Address
Your Mobile Number
Mobile Number
Your Organisation Name
Relationship to Rangatahi
Has Rangatahi given consent for this referral?
Yes
No
Rangatahi Details -
Robot Programme Specific School Details
Name of the School where the robot will be used
Contact Name at the School
Email Contact for School
Rangatahi Contact Details
Pronouns
Please select...
she/her/hers
he/him/his
any
he/they
other/ask me
she/they
they/them/theirs
If Other please share the pronouns of the rangatahi
Gender
First Name
Last Name
Date Of Birth
Ethnicity
Please select...
Pākehā
Māori
Pacific Peoples
Asian
Middle Eastern
Other
If Other, Please Share Ethnicity
Mobile Number
Email Address
Address Details
Address
Address 2
City/Town
Post Code
Country
Contact Information