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Request for Support Form (RFS)
To be completed with whānau input and consent
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Date of request
MM
/
DD
/
YYYY
Name of Requestor
Your answer
Verbal Consent obtained from whanau?
Yes
No
Clear selection
Requestor information
School Request (have you viewed Leading Lights?)
Mana Ake
Self - Refer
Group request
Yes
No
Clear selection
Number of students
Your answer
Individual request
Yes
No
Clear selection
Name of child
Your answer
School
Your answer
Gender
Your answer
DOB
MM
/
DD
/
YYYY
NSN
Your answer
Year
Your answer
Age
Your answer
Ethnicity
Your answer
Iwi
Your answer
Teacher (name and email address)
Your answer
Attendance (percentage) the student is enrolled and attending
Your answer
Legal guardian - relationship to child
Your answer
Is this shared custody arrangement?
Yes
No
Clear selection
Whānau contact details (please include address, email and phone number of all if shared custody)
Your answer
Are any other services currently involved
Yes
No
Clear selection
Comment
Your answer
Please outline a brief summary what you are hoping Mana Ake to achieve? (SMART - specific, measurable, attainable, relevant, time-based)
Your answer
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