Active Families Self Referral Form

First Parent/Guardian
Second Parent/Guardian
First child
Gender
Second child
Gender
Third child
Gender
Fourth child
Gender
Fifth Child
Gender

By checking the box we give consent for Sport Wellington to get information from our medical centre necessary for the programme and for our GP to be updated about our progress.  In signing up to take part in Active Families we will do our best to get involved and participate but understand that we can stop being on the programme at any time.

A confirmation email will be sent to you within 7 working days. If you have any queries please contact the GRx Maternal Lead on (04) 380 2070 or email at grx@sportwellington.org.nz