Elevate Youth Collective Application Form

Elevate Youth Collective

Registration form for Elevate Youth Collective. Intake for term three, a nine-week programme, 2026. Please note, for privacy reasons, there is no ability to “save your progress” on this web-form. Please email hello@elevate.org.nz or call 09 636 4763 between 9:00am – 4:00pm Monday – Thursday; if you have any trouble filling in this form, would like to receive a paper registration form, or would like over-the-phone assistance in filling in your registration form.

Participant Details (Section 1/11)

Participant Details – Participant Name(Required)

Your young person’s name.

First Last

Participant Details – Gender(Required)

Your young person’s gender.

Female

Male

Participant Details – Date of Birth(Required)

Your young person’s date of birth.

Participant Details – Street Address(Required)

Please write your young person’s home address. Addresses must be located in New Zealand. Please note the programme is run in-person in Onehunga, Auckland.

Participant Details – Suburb Name(Required)

Please write the suburb your young person resides in . Addresses must be located in New Zealand. Please note the programme is run in-person in Onehunga, Auckland.

Participant Details – Town Name(Required)

Please write the town your young person resides in. Towns must be located in New Zealand. Please note the programme is run in-person in Onehunga, Auckland.

Participant Details – Postcode(Required)

Please write your young person’s address postcode.

Participant Details – Ethnicity(Required)

Please describe the relevant ethnicities of your child. E.g. Māori, Fijian

Participant Details – Church Attendance

Does your young person attend Church? Your answer will NOT affect your application process. Participants DO NOT have to be Christian or affiliated with a church to attend.

Yes

Prefer not to say

Strengths and Interests (Section 2/11)

Strengths and Interests – What areas of interest does your young person have?

E.g. Enjoys crafts or outdoor sports. Please describe.

Strengths and Interests – What strengths does your young person have?

E.g. Positive characteristics of their personality. Please describe.

Medical Information (Section 3/11)

Medical Information – Does your young person have a disability, diagnosis, medical condition or learning difference?(Required)

Please select one.

Yes

Medical Information – Please tick all disabilities or medical conditions that may apply:

Cognitive

Neurodivergence (E.g. Autism, ADHD)

Physical

Mental Health

Medical

Other

Medical Information – If other, please describe:

Medical Information – Does your young person have any food sensitivities/diet requirements?(Required)

E.g. gluten free, food pureed. Please select one.

Yes

Medical Information – If yes, please describe:

Medical Information – Does your young person have any allergies?(Required)

E.g. fish oil, hayfever. Please select one.

Yes

Medical Information – If yes, please state the allergy and describe the severity of the allergy:

Medical Information – Does your young person take any medication?(Required)

Include self-administered and those used infrequently or only when needed (e.g. asthma or response to allergies). Please select one.

Yes

Medical Information – If yes, please list the medications:

Medical Information – My young person's behaviour may indicate a medical problem requiring immediate attention when:

Please describe.

Medical Information – My young person is prone to seizures:(Required)

Please select one.

Yes

Medical Information – Any other additional helpful comments regarding medical information?

Please describe.

Medical Information – Please write your family doctor’s name:(Required)

Medical Information – Please write your family doctor’s practice/clinic:(Required)

Medical Information – Please write your family doctor’s phone number:(Required)

Sensory, Behaviour and Communication (Section 4/11)

Sensory, Behaviour and Communication – How does your young person best communicate with others?

Sign language

Written language (English)

Communication device

Combination of all above

Other

Sensory, Behaviour and Communication – If you selected other, please describe how your young person best communicates with others:

Please describe.

Sensory, Behaviour and Communication – How would you feel about us encouraging your young person to try an activity they may be hesitant to do?(Required)

Please describe.

Sensory, Behaviour and Communication – Any sensory needs to be aware of? What sensory experiences do they avoid/seek?

Please describe.

Sensory, Behaviour and Communication – My young person may be trying to communicate their need for ___ (describe)___ when they exhibit the following behaviour:

Please describe the need of the young person that they may be communicating through particular behaviours.

Sensory, Behaviour and Communication – If your young person experiences a period of frustration/meltdown how do they calm themselves?(Required)

What strategies work at home/school/work? Please describe.

Sensory, Behaviour and Communication – A trigger-point for frustration, resistance or behavioural challenge may emerge for my young person when:(Required)

Please describe.

Sensory, Behaviour and Communication – Anything your young person may have an aversion to (e.g. sounds, lights, smells):

Please describe.

Sensory, Behaviour and Communication – Any other additional helpful comments for sensory, behaviour or communication?

Please describe.

Programme and Activity Support Needs (Section 5/11)

Programme and Activity Support Needs – Preparing food(Required)

Please indicate what activities your young person can do either independently, with some assistance, or supported. This question is regarding ‘Preparing food’.

Preparing food – Independently

Preparing food – With some assistance

Preparing food – Supported

Programme and Activity Support Needs – Eating lunch(Required)

Please indicate what activities your young person can do either independently, with some assistance, or supported. This question is regarding ‘Eating lunch’.

Eating lunch – Independently

Eating lunch – With some assistance

Eating lunch – Supported

Programme and Activity Support Needs – Making hot drinks(Required)

Please indicate what activities your young person can do either independently, with some assistance, or supported. This question is regarding ‘Making hot drinks’.

Making hot drinks – Independently

Making hot drinks – With some assistance

Making hot drinks – Supported

Programme and Activity Support Needs – Staying hydrated(Required)

Please indicate what activities your young person can do either independently, with some assistance, or supported. This question is regarding ‘Staying hydrated throughout the programme’.

Staying hydrated throughout the programme – Independently

Staying hydrated throughout the programme – With a reminder/prompt

Programme and Activity Support Needs – Being sun-smart(Required)

Please indicate what activities your young person can do either independently, with some assistance, or supported. This question is regarding ‘Being sun-smart’.

Being sun-smart – Independently

Being sun-smart – With a reminder/prompt

Being sun-smart – Supported

Programme and Activity Support Needs – Using craft tools(Required)

Please indicate what activities your young person can do either independently, with some assistance, or supported. This question is regarding ‘Using craft tools e.g. scissors, hot glue gun’.

Using craft tools e.g. scissors, hot glue gun – Independently

Using craft tools e.g. scissors, hot glue gun – With some assistance

Using craft tools e.g. scissors, hot glue gun – Supported

Programme and Activity Support Needs – Using outdoor tools(Required)

Please indicate what activities your young person can do either independently, with some assistance, or supported. This question is regarding ‘Using outdoor tools e.g. rake, broom, secateurs’.

Using outdoor tools e.g. rake, broom, secateurs – Independently

Using outdoor tools e.g. rake, broom, secateurs – With some assistance

Using outdoor tools e.g. rake, broom, secateurs – Supported

Programme and Activity Support Needs – Using digital devices(Required)

Please indicate what activities your young person can do either independently, with some assistance, or supported. This question is regarding ‘Using digital devices e.g. computer, TV, phone’.

Using digital devices e.g. computer, TV, phone – Independently

Using digital devices e.g. computer, TV, phone – With some assistance

Using digital devices e.g. computer, TV, phone – Supported

Programme and Activity Support Needs – Any other additional comments for supports during the programme and activities?

Please describe.

Transitions and New Settings (Section 6/11)

Transitions and New Settings – Does your young person have any routines or habits that are really important to them to follow?

Please describe.

Transitions and New Settings – Do changes in routine/ transitions between activities affect your child's behaviour?(Required)

Please select one.

Yes

Transitions and New Settings – If yes, how?

Please describe.

Transitions and New Settings – What setting is your young person most relaxed?(Required)

Please select one.

Lone

A few young people

Many young people is okay

Transitions and New Settings – What support with changes and transitions does your young person need?

Please describe.

Transitions and New Settings – Any other additional helpful comments for transitions and new settings?

Please describe.

Personal Cares (Section 7/11)

Personal Cares – Does your young person need assistance with toileting?(Required)

Please select one.

Yes

Personal Cares – Does your young person require toilet reminders during the day?(Required)

Please select one.

Yes

Personal Cares – Does your young person commonly have toileting accidents?(Required)

Please select one.

Yes

Personal Cares – If necessary, do you give consent for staff to assist your young person with toileting or showering /changing?(Required)

Please select one.

Yes

Personal Cares – Any other additional helpful comments for personal cares?

Please describe.

Fitness and Mobility (Section 8/11)

Fitness and Mobility – How would you describe your young person’s fitness?(Required)

Please describe.

Fitness and Mobility – How would you describe your young person’s mobility?(Required)

Independent (walks unaided)

Uses crutches

Uses a walking frame

Uses a manual wheelchair

Uses an electric wheelchair

I use a combination of ways of getting around

Other

Fitness and Mobility – If your young person uses a combination of ways of getting around, please describe:

Please describe.

Fitness and Mobility – Any balance, coordination or physical challenges?(Required)

Please select one.

Yes

Fitness and Mobility – If yes, please describe:

Please describe.

Fitness and Mobility – Any other additional helpful comments for fitness and mobility?

Please describe.

Contact Details (Section 9/11)

Contact Details – Participant's Email (If applicable)

Please state.

Contact Details – Participant's Phone Number (If applicable)

Please state.

Contact Details – Legal Guardian/Parent Name(Required)

First Last

Contact Details – Legal Guardian/Parent Address (If different from Participant's address at beginning of form, if not, leave blank).

Contact Details – Legal Guardian/Parent Email(Required)

Contact Details – Legal Guardian/Parent Work Phone Number(Required)

Contact Details – Legal Guardian/Parent Cell Phone Number(Required)

Contact Details – Emergency Contact Name(Required)

First Last

Contact Details – Emergency Contact's Relationship to Participant(Required)

Please state the Emergency Contact’s Relationship to the Participant. E.g. Friend, co-worker, Aunty, Uncle

Contact Details – Emergency Contact Email(Required)

Contact Details – Emergency Contact Cell Phone Number(Required)

Payment and Funding (Section 10/11)

Payment and Funding – Payment Method(Required)

Please select one.

Invoice and Bank Deposit (Self-funded)

Respite Funding

Other

Payment and Funding – If other, please describe:

Payment and Funding – Name of your funding provider (if relevant)

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