Registration Form

1.

First name

* required

Maximum 50 characters

0/50

2.

Last name

* required

Maximum 50 characters

0/50

3.

Your email address

* required

4.

What is your connection to the Maungakiekie-Tāmaki Local Board area? (select as many that apply)

5.

What suburb or neighbourhood do you live in?

Select option

6.

What age group do you belong to?

14 - 16 years

17 - 19 years

20 - 22 years

23 - 24 years

8.

What gender are you?

Male

Female

Another gender

9.

Do you consider yourself to be part of the LGBTIQA+ community?

Yes

No

Prefer not to say

10.

Do you have any difficult seeing, even if using glasses?

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

11.

Do you have any difficult hearing, even if using a hearing aid?

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

12.

Do you have any difficulty walking or climbing steps?

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

13.

Do you have any difficulty remembering or concentrating?

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

14.

Do you have any difficulty washing all over or dressing?

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

15.

Do you have any difficulty communicating using your usual language, for example understanding or being understood by others?

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

About the project

Some more information about you