THA Consent Form 1. Kiritaki/Client InformationName First Last Date of Birth Day Month Year Address Street Address Address Line 2 City ZIP / Postal Code PhoneEmail 2. Service EnrolmentI, the undersigned, consent to enrolling in the services provided by Te Hau Awhiowhio o Otangarei trust. I understand that participation in these services is voluntary and that I may withdraw at any time by providing written notice.3. Information Sharing ConsentI give permission for Te Hau Awhiowhio o Otangarei Trust. to collect, use, and share my personal information within its services and associated programs to provide coordinated care and support. I understand that my information will be used only for the purposes of service delivery, assessment, and referrals within the organisation.4. Confidentiality and PrivacyI acknowledge that Te Hau Awhiowhio o Otangarei Trust will handle my personal information in accordance with the Privacy Act 2020 and other relevant New Zealand laws. My information will not be shared with external parties without my consent unless required by law or in situations where there is an immediate risk to my safety or the safety of others. I also understand that due to reporting purposes my information may be a random pick from an external funder to audit records to ensure Trust Standards are met.5. Declaration and SignatureDeclaration I confirm that I have read and understood this form. I consent to the collection, use, and sharing of my personal information as outlined above.NameThis field is for validation purposes and should be left unchanged. Δ Download Blank Consent Form
