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Faculty of Medical and Health Sciences

Whakapiki Ake Pukatono (registration form)

Fields with (*) are mandatory.

Section One - Eligibility
Are you currently a secondary school student?*
How long have you been out of secondary school?*
Have you done any relevant tertiary study/work experience since leaving secondary school?*
What school do you attend? *
What school year are you in? *
Are you interested in pursuing a career in health?*
Are you descended from a Māori (that is, did you have a Māori birth parent, grandparent, great grandparent etc)?*

Section Two - Student Details
First names:*
Last Name:*
Gender:*
Date of birth:*
Email:*
Mobile phone:*
Home phone:*
Facebook name:
Postal Address:*
Suburb:
Town/City:*
Post Code:

Parent/Legal Guardian Details
First name:*
Last name:*
Relationship to you:*
Mobile phone:*
Home phone:*
Email:*
Address if different from yours:

Section Three - Iwi Affiliation
Which Ethnic Group do you belong to?
Mark the box or boxes which apply to you.		 New Zealand European
Māori
Samoan
Cook Island Māori
Tongan
Niuean
Chinese
Indian
Other
Please state: *
Please complete if you can identify your;
Iwi:
Hapū:
Marae:

Section Four - Recruitment Information
What Health Career/s are you interested In?
Mark all that apply to you.*		 Medicine
Pharmacy
Nursing
Health Sciences
Optometry
Unsure
Other
Please state: *

What subjects have you taken/currently enrolled in? (Year 11-13 only)

Table A Yr11
level 1		 Yr12
level 2		 Yr13
level 3		 Table B Yr11
level 1		 Yr12
level 2		 Yr13
level 3		 Other Yr11
level 1		 Yr12
level 2		 Yr13
level 3
Classics Studies Accounting Maths
English Biology General Science
History Chemistry P.E
Geography Economics Health
History of Art Calculus
Te Reo Māori Statistics
Physics
How did you hear about Whakapiki Ake?* Through school
Family/friends
Advertising
Expo
Other
Please state: *

By submitting this form, I declare that the information is true and correct ▶