Registration Form

Block/Capital Letters are appreciated please

Client Contact Details

Date

Name
Home Address

Home Phone
Mobile
Email
Would you like to receive Emerges Newsletter?

Yes/No

Alternative Contact
Home Phone

Name
Relationship
Email

Work Phone
Mobile

Client Personal Details

Male/ Female
Birth Country
Ethnic Origin
Iwi Affiliation

Date of Birth
NZ Citizen Yes/No
Work Permit Yes/ No/ NA
Drivers License

Benefits (IB SB)

WINZ No

Benefit office

ORRs No

Yes/No

Other Agencies Involved

Agency
Contact Name

Agency
Contact Name

Agency
Contact Name

Phone
Email

Phone
Email

Phone
Email

Emerge Supported Employment Trust,

Level 3, 203 Willis Street, PO Box 27-187 Marion Square, Wellington 6141
Phone 04 384 7456, Fax: 04 384 7428 Email: enquiries@emergetrust.org.nz www.emergetrust.org.nz

Registration Form
Block/Capital Letters are appreciated please

Job Search Information

Preferred working hours
Preferred working environment
Preferred working location

Client Employment Support Details

Please describe your experience of disability

What does this mean for you?

Any equipment needed to

support you in your work?
Modifications to work environment

Any other supports in the

workplace required?
Ongoing related supports, adaptation to
the work environment etc.

Any related health issues or

medication (if relevant)?

Disclosure Agreement
I agree that relevant information may be provided to, or collected from, other
organisations on my behalf.
Other organisations that may be included are:- previous and potential employers, support agencies,
educational and training organisations, and other relevant services .

Client Name
Signature
Date

Emerge Staff
Signature
Date

Emerge Supported Employment Trust,

Level 3, 203 Willis Street, PO Box 27-187 Marion Square, Wellington 6141
Phone 04 384 7456, Fax: 04 384 7428 Email: enquiries@emergetrust.org.nz www.emergetrust.org.nz

Registration Form
Block/Capital Letters are appreciated please

Privacy Act (1993) Requirements

The personal information given by _________________________________ (job seeker or
parent/guardian in respect of that person) to Emerge Supported Employment Trust has
been voluntarily provided. It is to be used for the purpose of providing career planning,
placement, employment, work experience or a training support service. Emerge may also
use this information for statistical, research and funding purposes, but in doing so Emerge
will ensure that no individual can be identified, except where permission has been
obtained.

The information provided may be shared with members of the career planning team,
employers, and training providers to the extent that is appropriate. All those employed by
Emerge who have access to this information including volunteers are bound by the terms
of their engagement to keep this information confidential.

In addition I ___________________________ (name) hereby give permission for my

WINZ number (or name and date of birth if I do not have a WINZ number) to be used as
part of Emerges reporting obligations to Work and Income New Zealand.

_____________________________ (name) has access and rights of correction at any

time.

Should __________________________ (name) choose to no longer access

Emerge services all personal information will be destroyed after a period of 5 years, from
the last contact.

Privacy Act Agreement

Client Name

Parent /
Guardian

Signature

Signature

Date

Date

Emerge Staff
Signature

Date

Emerge Supported Employment Trust,

Level 3, 203 Willis Street, PO Box 27-187 Marion Square, Wellington 6141
Phone 04 384 7456, Fax: 04 384 7428 Email: enquiries@emergetrust.org.nz www.emergetrust.org.nz