Registration of Interest formfor Certificate of Proficiency in Pacific Nutrition

Date of course
Location (eg Auckland)

PERSONAL INFORMATION

Title (Miss/Ms/Mrs/Mr) / First Name / Last Name
Date of Birth
Residency*(please tick which applies to you) / NZ citizen NZ permanent resident Non-resident
*proof required

Ethnic Group (please tick which applies to you):

NZ European Maori Samoan Cook Island Maori Tongan Niuean ChineseIndian

Other (such as Tokelauan, Fijian, Tuvaluan, Dutch, Japanese - please specify)

Address Details:

Street address
Suburb
City
Postcode

Contact details:

Phone / Mobile
Email

Emergency contact:

Name / Phone

EDUCATION

Please indicate your highestlevel of Education (please tick which applies to you)

Secondary Tertiary Trade None

EMPLOYMENT and COMMUNITY BACKGROUND

Are you currently employed? Yes No

If you are employed, what is the name of the organisation you work for?

What is your job title?

Which community or organisation do you represent at this training/ course?

Goals:

What do you want to achieve fromcompleting the course? (please tick all that apply)

 Increase knowledge and skills

 Gain confidence in cultural engagement

 Improvedelivery of education sessions

 To better support others to live a healthy lifestyle

 For career progression

How did you hear about the Pacificnutrition course?

Through Work  Church Friends  Internet Facebook Other

Thank you for completing the registration form.

Once you have signed and dated this form below, please refer to the course checklist for instructions and details of other documentation* you are required to submit with your application.

Applicant signature Date

Use of Information

By signing this document I understand that my information will be used by the National Heart Foundation on an electronic database. In providing this information I understand that it will be used for statistical purposes and for sending me information relating to the business of National Heart Foundation only, and will otherwise be treated in confidence and not shared with external sources. I understand that I have the right to access my personal information, to request changes to my personal information or to request that my personal information be removed from the database at any time. I understand that the information I provide will be used in accordance with the provisions of the Privacy Act 1993. I understand any photographs taken during the course may be used in National Heart Foundation publications or promotional material.

ROI CPPN 052517