Your Name (required)

Your Email Address (required)

Child’s Full First Name (required)

Child's Last Name (required)

Child's Date of Birth (required)

Child’s NHI Number (required)

Gender (required)
---MaleFemale

Ethnicity (required)

Child's Address (required)

Names of Parents/Guardians (required)

Phone Numbers of Parents/Guardians (required)

Mobile Number (optional)

Email Address of Parents (optional)

What diagnosis has the child received? (required)

Who made the diagnosis? (required)

Where was the diagnosis made?
(e.g, Whakatata House, Dunedin Hospital) (required)

When was the diagnosis made? (required)

Provide details of adult family/whanau members interested
in participating in the ASD Plus programme e.g. grandparent, parents, aunt (required)

If there are any days and times you are not able to participate
in the programme please indicate here (optional)

Please check the box to confirm your Interest in the
ASD Plus: Education for Families Programme (required)

 i confirm my interest in the programme