EmailMe Form - Heart Kids NZ Membership Form

Part A - Heart Child / Teen / Adult / Prenatal Details
Are you a heart child, heart teenager, heart adult or a parent expecting a heart child? *
If you are expecting a heart child, please select Prenatal.
Title:
First Name: *
Middle Name:
Last Name: *
Preferred Name:
Date of Birth: *
DD / MM / YYYY
Ethnicity: *
Providing this information will assist with family matching. Demographic information is also very helpful in assisting with research projects and funding opportunities.
European:
Pacific Island:
Asian:
Address: *
Town/City: *
Type the first letter of your town/city and the list will drop down to the towns/cities beginning with the same letter.
Postcode: *
Click Here for the Address and Postcode Finder
Mobile Number: *
Email: *
Congenital Heart Condition (Primary Diagnosis): *
Only one condition can be selected. If there are two or more conditions, please select Multiple Heart Defects.
Congenital Heart Condition (Secondary Diagnosis):
Acquired Heart Condition (Primary Diagnosis): *
Procedure: *
Only one procedure can be selected. If there have been two or more procedures, please select Multiple Procedures.
Other Associated Conditions: *
Only one condition can be selected. If there are two or more conditions, please select Multiple Conditions.
What else would you like us to know?
Part B - Parent / Primary Caregiver and/or Next of Kin
The Parent/Primary Caregiver will receive all information, including post, for heart children and teens under 18 years.
Title: *
First Name: *
Last Name: *
Preferred Name:
Date of Birth:
DD / MM / YYYY
This information helps us secure funding opportunities.
Ethnicity: *
Providing this information will assist with family matching. Demographic information is also very helpful in assisting with research projects and funding opportunities.
European:
Pacific Island:
Asian:
Relationship to Heart Child/Teen/Adult: *
Address details the same as Part A? *
Yes
No
Address: *
Town/City: *
Type the first letter of your town/city and the list will drop down to the towns/cities beginning with the same letter.
Postcode: *
Click Here for the Address and Postcode Finder
Mobile Number: *
Secondary Mobile Number:
Email:
Would you like to add a Secondary Contact? *
Yes
No
Part B - Parent/Caregiver/Next of Kin - Secondary Contact
The Secondary Contact will receive postal communication if address is different from Primary Contact. Otherwise, they will receive all email communication if a different email is provided from Primary Contact.
Title: *
First Name: *
Last Name: *
Preferred Name:
Date of Birth:
DD / MM / YYYY
This information helps us secure funding opportunities.
Ethnicity: *
Providing this information will assist with family matching. Demographic information is also very helpful in assisting with research projects and funding opportunities.
European:
Pacific Island:
Asian:
Relationship to Heart Child/Teen/Adult: *
Relationship to Primary Contact: *
Address details the same as Part A? *
Yes
No
Address:
Town/City:
Type the first letter of your town/city and the list will drop down to the towns/cities beginning with the same letter.
Postcode:
Click Here for the Address and Postcode Finder
Mobile Number: *
Email:
Part C - Personal Privacy and Communication
I wish to receive email communication from Heart Kids NZ. *
Yes
No
The personal information provided in this form will be held by Heart Kids NZ and used by us and any of our affiliated branches for the purpose of administering your membership and providing you with the information you need about Heart Kids NZ. You may at any time access and amend any of the personal information we hold about you. Further information regarding the Heart Kids NZ privacy policy can found on our website. Heart Kids NZ uses email to share important information and newsletters with our members. We will only send this to you if you wish to receive it.
How did you hear about Heart Kids NZ? *
Part D - Declaration Statement
All the information provided on this form is true and correct and I agree to abide by Heart Kids New Zealand's constitution and related policies.
Name: *
Date: *
DD / MM / YYYY
Signature:
Clear
To sign please use your mouse if using a PC or directly on the screen if using a smart device (e.g. phone or iPad)