Join GRSNNZ Network

*(denotes required field)

First Name: *

Last Name: *

E-Mail Address: *

E-Mail Address again: *

Please enter your E-mail Address a second time.

Title *

Mr
Mrs
Ms
Miss.

Street Address *

City/Town *

Area *

Auckland Bay of Plenty Canterbury Gisborne Hawkes Bay Marlborough Nelson Otago Southland Taranaki Tasman Waikato Wanganui-Manawatu Wellington West Coast Other

Postcode *

Do you live in NZ? *

Yes
No.

Country and Area if not NZ

Home Phone (include area code) *

Partner's Name

Username at Crying Over Spilt Milk and/or www.everybody.co.nz

Ethhic Group *

NZ European
Maori
Pacific Islander
Asian
Chinese
Indian
Other

Other Ethnic Group

First contact,/ how did you hear about us? *

Do you give consent to be added to the Yahoo! Group for your local support group(s) meetings and contacts? *

Yes
No

Do you give consent to be on the GRSNNZ email list? (Quarterly newsletters and occasional emails about events relevant to your area.) *

Yes
No

 

FOR STATISTIC/FUNDING PURPOSES:

Date of birth of person with Gastric Reflux or associated condition: (You will be given the option to add additional family members when this form has been submitted) *

Are they under specialist care? *

Yes
No

Have they had a formal diagnosis of...(select all that apply) *

Gastric Reflux Disease - Silent
Gastric Reflux Disease - Visible
Adult Gastric Reflux /GORD
Cleft palate
Coeliac Disease
Gluten sensitivity/intolerance/allergy
Milk protein allergy/intolerance
Lactose intolerance
No diagnosis

No diagnosis details - i.e. reason for joining GRSNNZ

Other medical conditions or disabilities that we may be able to help you with - Details?

Medications currently prescribed? *

Current feeding type: - formula/breastfed/formula type/special diets *

Anything you would like to add:

 

CONFIDENTIALITY

It has come to the committee's attention that a confidentiality agreement with all parents/members/coffee/support group conveners/committee, staff and support agencies is needed. Please find below our agreement of Confidentiality for you to read and agree to. This agreement will protect all parties when sharing personal details with GRSNNZ and associated services. For those of you who have shown interest in attending a local support group meeting, becoming support parents or committee members this agreement is necessary for participation.

AGREEMENT

Members, Support Parents, GRSNNZ, committee members & Associates will treat the families they support with dignity, honesty and will respect their values, feelings, beliefs and right to privacy. All information and communication will be held confidential within GRSNNZ and associated services. All information about the family is protected. Support parents do not discuss or disclose any information about the child or the family to anyone except to their GRSNNZ, Crying Over Spilt Milk, Coordinator or Manager, unless there has been written permission from parents prior. Members who are privilege to GRSNNZ or COSM management information and processes will respect the sensitive nature of this information and agree not to share confidential material with other organisations including all documents with copy right. You may at anytime access and correct your information. Privacy Act. 1994. Using provisions within the Privacy Act, any unlawful act can be reported to the appropriate authorities.

AGREE? *

Yes
No

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