DFT Enrolment Form with Scholarship

Parent/Caregiver Information
Parent/Caregiver 1 Full Name*

First NameLast Name
Mobile Phone*
Home Number
Please include local area code
Work Phone
PLease include local area code
Email*
example@example.com
Relationship to Teen*
Parent/Caregiver 2 Full Name

First NameLast Name
Mobile Phone
Home Number
Please include local area code
Work Number
Please include local area code
Email
example@example.com
Relationship to Teen
Emergency Contact

(Will be used if the above cannot be contacted)
Emergency Contact Full Name*

First NameLast Name
Mobile Phone*
Home Number
Please include local area code
Work Number
Please include local area code
Relationship to Teen*

Family Information
Discovery is a safe and unique environment where teenagers from a variety of backgrounds spend seven days exploring the idea of what it is to be a useful member of society. Discovery is a successful programme because of the diversity of its participants. Due to the teen culture that is currently experienced in New Zealand, we need to know about the experiences of the participants in order to provide the best Discovery experience for each group of teenagers. Please answer these questions as honestly as possible.
What are you hoping to gain from Discovery?
What area of life would you like your teenager to improve?
Describe your relationship with your teenager:
Please tell us about any consultation that your teenager has undertaken with psychiatrists, psychologists (other than vocational), or therapist(include dates). Also include involvement with CFYS / Oranga Tamariki etc.
Please tell us of any extreme traumatic events that may have had a lasting effect on your teen (include dates).
Is there any area of your teen’s behaviour that you have concerns about?
Have you ever seen evidence of the following? * (Required to comply with health and safety regulations.)

Victim of bullyingExperimentation with alcohol and/or recreational drugsSelf-HarmTheft of money or other personal items from your familyBackground of abuseSuicide, including amongst teen’s peer group
*Please provide details:
Please tell us anything else you want us to know:

Parent's Day
Parent’s day is an important part of the Discovery Programme. It is an opportunity for parents and caregivers to learn about what their teen has done over the week and how to support them to continue using the Discovery tools in their life. It is important that at least one person attends for your teen.

Registration for Parent day is from 9.00am - 9.30am on the final day of the programme (Saturday). Morning tea, lunch and afternoon tea are provided for two parents/caregivers. Parents day will finish at approximately 5.00pm.

For catering purposes on Parents Day, 2 parents/caregivers are included in the registration fee to attend the day, please contact the office if you would like additional caregivers to attend.
1. Parents/Step Parents/Grandparent/Guardian Attending:*
Full Name
Dietary Requirements:*
Relationship to Teenager*
2. Parents/Step Parents/Grandparent/Guardian Attending:
Full Name
Dietary Requirements:
Relationship to Teenager

Financial Information for Scholarship application
Please indicate the total combined household income per year

$0 - $35,000$35,000 - $50,000$50,000 - 70,000$70,000 - $100,000Over $100,000
What other financial options have you considered (e.g. funding from family, community organisations such as Rotary, Lions, workplace) and what responses, if any have been received?
Most Discovery Scholarships are partial funding. How much can you contribute towards your teen attending?
What benefits/outcomes do you hope/expect for your teen and family?
What are your reasons for making this application for funding?
Agreement to Recognise and Feedback to Sponsor/s:
Discovery Foundation is reliant on generous sponsors and has obligations to them. These individuals and groups provide sponsorship and in return only wish to know donations have been well spent and made a difference to recipients. Discovery Foundation requests all scholarship recipient parent and children to provide this feedback within 4 weeks of programme completion. This ‘expression of thanks’ should outline the experience of the child and parents of Discovery and any positive changes that have been attributed to the course. Feedback should be provided to the Discovery offices via post (PO Box 90 377 Victoria Street West, Auckland 1142) or email admin@discoveryforteens.org.nz.

By completeing and/or signing this form you agree to provide written feedback and thanks to sponsor/s. You also acknowledge that if you fail to provide this the scholarship may be revoked and Discovery Foundation may require you to pay the outstanding amount which may have otherwise been covered by sponsored scholarship.

Privacy Act
Pursuant to the PRIVACY ACT 1993 the following is brought to your attention:
a) This application collects personal information about you;
b) The information is being collected to determine your suitability to receive a scholarship towards the Discovery programme fee;
c) The intended recipients of the information are Discovery Foundation and any third party that
Discovery may apply for funds from on behalf of the applicant
d) The information is being collected and held by Discovery Foundation Inc., PO Box 90 377, Victoria St West, Auckland;
e) Failure to provide this information may result in your application for a grant being declined;
f) You have rights of access to, and correction of this information.
Signatures - I/we have read and understood this application. I/we confirm that the information supplied by me/us is true and complete and understand that it has been given to enable the receiver to consider this grant application. I/we understand that there is a requirement to provide written feedback and thanks to sponsors:
Yes I agree and understand the above

Yes I agree and understand
Parent/Caregiver Name

First NameLast Name
Today's date

MonthDayYear
Date

Terms & Conditions
PAYMENT

Paying your course fee
A deposit is required at the time of booking to secure your teens place. Full payment is required 3 weeks before your course start date. Course fees are in NZ dollars and are GST inclusive.

Refunds
Your course fee, less your deposit, is refundable up to 21 days before your course start date. (Deposits are non-refundable except for medical reasons, at which point a medical certificate is required for cancellation).

Cancellations / Transfer
The deposit amount is non-refundable. If parent(s)/caregivers cancel 21 days or more before discovery begins then a refund minus the non-refundable deposit will be paid. If cancellation occurs less than 21 days before Discovery begins, there is no refund and any outstanding monies will be invoiced to the customer. The Discovery fee is able to be transferred to another Discovery being run in the next 12 months. The transfer fee is $100. (Transfers are not applicable to scholarships provided by Discovery).

Departure
If you depart early or are sent home from your course, the course fee is not transferable or refundable.

PRIVACY

Personal information
Your personal information will be held confidential to Discovery Foundation, in accordance with the Privacy Act (1993), for the purposes of Discovery courses and associated administration.

You have the right to see all information held by Discovery and may ask at any time for that information to be corrected. You authorise Discovery the right to send a copy of your Feedback to your sponsors, including employers, if requested and applicable.
Graduation list - I consent for my teenager's name and contact details to appear on the Discovery Graduate List given to participants*

YesNo
Database - I consent for my name to be kept on the Discovery Foundation database for the purposes of ongoing communication.*

YesNo
Smoke, drug & alcohol free
No alcohol or non-prescription drugs are permitted. Some venues may be smoke-free. Please check with the office.
Confirmation of your enrolment is subject to teens approval from Discovery Foundation. This is to ensure your safety, the safety of others, and quality course outcomes for all. By completing this form I acknowledge Discovery will contact me by email and/or phone to complete registration:*

Yes I acknowledge this statement
Parent / Caregiver Declaration
• I have read and agree to the above Terms and Conditions.
• The Discovery programme is designed to produce maximum benefits for everyone involved. To support the programme, we ask everyone to abide by some agreements. We realise that everyone will naturally and easily keep many of these agreements, and yet we know what value is achieved when everyone has read and signed them. Your teenager has a set of these agreements to sign in their part of this pack, please also have a read through them. I understand that during my teen’s stay at Discovery, any breach by my teen of Agreements 9 to 15 inclusive (teen agreement page), can result in us being notified, transport being arranged, and my teen being sent home from the programme with at my cost and with NO REFUND.
• I understand that, except as expressly permitted by law, if I give false information, withhold relevant information, or do not advise of any new relevant information, and that if I do not comply with the above Terms and Conditions, my teens enrolment may be cancelled or my teen sent home at my own expense.

Promotional material - I authorise Discovery the right to use my teens images that are obtained in relation to their Discovery participation and to disclose this information to third parties for marketing and public relations purposes; these materials will remain the property of Discovery. I also accept that Discovery Foundation will not be liable or any unauthorized use of the images, as long as it takes all reasonable precautions to ensure the images are only used for authorized purposes.
Yes I have read and understood the Parent / Caregiver Declaration
Name*

First NameLast Name
Today's Date*

DayMonthYear
Date
Enter the message as it's shown*
We will be in contact with you within 3 working days of receiving your form. If you have not heard from us in 3 working days please contact us: admin2@discoveryforteens.org.nz
Should be Empty:

Teen Enrolment with Scholarship Application

Parent/Caregiver Information

Emergency Contact

Personal Details

Family Information

Parent's Day

Financial Information for Scholarship application

Agreement to Recognise and Feedback to Sponsor/s:

Terms & Conditions

Parent / Caregiver Declaration