Kia Ora Ake Consent Form

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0800 Te Whare
(0800 839 4273)

Pātai? Questions? Reach out anytime.

kiaoraake@tewhare.org.nz

Kia Ora Ake is a free,
school-based hinengaro wellbeing service

I give consent for our child / tamaiti / mokopuna(Required)

First name Last name

Kura:(Required)

Programme:(Required)

to have contact with Kia Ora Ake and to receive hinengaro wellbeing support through:(Required)

Individual support (short term 1:1 support or navigation)

Small group support (structured, therapeutic support to address wellbeing needs)

Some sessions may include shared food. Please list any food allergies, intolerances, or dietary needs here:

By completing this form, I understand that:

• Participation in the programme is voluntary. I can ask questions, update information, or withdraw my consent at any time.
• The programme will be explained to my tamaiti in an age-appropriate way.
• Personal information will be stored securely and used only for programme related purposes, respecting privacy and con dentiality. You can request copies of information Kia Ora Ake holds about your child. To discuss this, contact your Kia Ora Ake provider.
• If wellbeing concerns arise that may impact my tamaiti or others, kaimahi will communicate with me.
• If there are concerns for the safety of my tamaiti, kaimahi can follow school tamaiti / child protection protocols and seek additional support / advice.
• Kia Ora Ake is funded by Te Whatu Ora. If information needs to be shared with other services to ensure appropriate support, this will be discussed with you.

Consent for Photographs

I give permission for Kia Ora Ake kaimahi to take photographic images of my child for the purposes of sharing information or promoting activities related to Kia Ora Ake e.g. to use in brochures to share with other whaanau and schools &/or for schools to use in their newsletters for activities that are related to Kia Ora Ake.(Required)

Yes

Email Updates

You may receive occasional email updates featuring highlights and learning growth of your tamaiti / tamariki with some additional resources to support the ongoing progress of their wellbeing journey. By providing your email, you agree to receive these updates.

Your Name(Required)

First Last

Email(Required)

Phone

Relationship to child / tamaiti / mokopuna(Required)

Date