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First name
*
Last name
*
Preferred Name
Date of Birth
*
Day
/
Month
/
Year
Phone number
Email
*
Street address
Town
*
Do you have a MSD client number?
Please Select
Yes
No
If yes, what is your MSD client number?
Gender
*
Please Select
Male
Female
Non-binary
Other
Prefer not to share
Ethnicity
New Zealand European
Pacific People
Maori
Asian
Other European
Other
Do you have Iwi/hapu affiliation?
*
Please Select
Yes
No
If yes, please state your Iwi/hapu affiliation
Do you have a criminal record?
Please Select
Yes
No
What is your Highest Level of High School Qualification, on enrolment?
Please Select
No formal secondary school qualification
14 or more credits at any level
NCEA Level 1 or School Certificate
NCEA Level 2 or 6th Form Certificate
University Entrance
NCEA Level 3 or Bursary or Scholarship
Overseas qualification (includes International Baccalaureate & Cambridge Exams)
Other
Not known
Have you completed a qualification since leaving school?
Please Select
Yes
No
If yes, what is the highest level of qualification you've achieved since leaving school?
Please Select
No Qualification
Level 1 Certificate
Level 2 Certificate
Level 3 Certificate
Level 4 Certificate
Level 5 Diploma/Certificate
Level 6 Graduate Certificate, Level 6 Diploma/Certificate
Bachelor Degree, Level 7 Graduate Diploma/Certificate, Level 7 Diploma/ Certificate
Postgraduate Diploma/Certificate, Bachelor Honours
Masters Degree
Doctorate Degree
Not Stated
Emergency Contact Name
Emergency Contact Details
Do you have any health conditions we should be aware of?
Please Select
Yes
No
If yes, do you have a medical certificate?
What is your current drivers licence status?
*
Please Select
None
Learners
Restricted
Full
Do you have secure accommodation?
*
Yes
No
Unsure
Are you currently in an Education or Training Course?
School
Alternate Higher Education
Te Kura
Alternative School
Apprenticeship
Tertiary Education
None
Would you pass a drug test on intake?
*
Yes
No
Unsure
Support Required
Career advice & guidance
CV & CL writing
Interview assistance
Job hunting
Drivers licence
Upskilling/ micro credentials
Work readiness skill building
Financial Literacy
Health & Safety Awareness
Transition to work
Specialised Support Needed
Mental Health
Secure ongoing accommodation
Emergency accomodation
addiction support
Safety
Long term support
Health
Gang affiliations
Criminal Convictions
Other
Referred By
*
Self
Family
School
MSD
Other
If you were referred what are your referrer's contact details?
Are you a New Zealand resident or citizen?
*
Please Select
Yes
No
If no, what visa do you hold?
I give permission for Mayors Task Force for Jobs (MTFJ) to transport myself for the purposes of finding employment in a legal vehicle with a licenced driver.
*
Please Select
Yes
No
I give permission for the Mayors Task Force for Jobs to capture photos and video recordings of me and use them for promotions related to finding employment
*
Please Select
Yes
No
MTFJ Privacy Statement
I have read and agreed to the privacy statement for Mayors Taskforce for Jobs
*
You agree to your local council storing the information you provide in its local database
*
Please Select
Yes
No
You agree to MTFJ sharing your name, date of birth, MSD client number, contact details, employer details, highest educational achievement, driver license status, accommodation status, and details about your participation in the programme with MSD
*
Please Select
Yes
No
You agree to MTFJ sharing your name and contact details with MSD for them to contact you about your participation in the programme for research and evaluation
*
Please Select
Yes
No
Signature
*
Please write your full name here to confirm your submission
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