Ngati Kuta Registration Form

ngati kuta|hapu ki te rawhiti

Registration Form

PLEASE RETURN FORM TO: By post: Lara Clarke, 27 Clark Street, Hikurangi, Whangarei, New Zealand Or email: [email protected] More information: Ph: (09) 433 7368 or visit http://www.ngatikuta.maori.nz Those 18 years and over may complete their own form if they wish. PRINT CLEARLY. ….......................................................................................................... SURNAME: …………………................ FIRST NAME: .......……....................... MIDDLE NAMES: …………………….............…..................... GENDER .... M/F DATE OF BIRTH ..…/……/….. EMAIL ADDRESS ........................................ POSTAL ADDRESS ….………………………………………………………........................... Married/Partner/Single (Circle)

PARTNER’S NAME………………………….......

CHILDREN : (Please include birth dates) ……………………………………….......................................................... ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ ............................................................................................ FATHER’S NAME: …………………………….................. HAPU (Principal)………………….............................. MOTHER’S NAME: ……………………………................. HAPU(Principal)………........................................