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Homeguard Information
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Homeguard Information Update
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Thank you for taking the time to fill up this form. We collect this information in order to ensure that our information is up to date and relevant. If you have any questions about the form or anything else, please reach out to us!
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(Please leave blank if you do not wish to provide that information or if it is not relevant for you.)
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First Name
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Last Name
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Email
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Auckland
Auckland - Far North
Auckland - North
Auckland - South
Auckland - East
Auckland - Central
Auckland - West
Bay of Plenty
Canterbury
Gisborne
Hawke's Bay
Manawatu-Wanganui
Marlborough
Nelson
Northland
Otago
Southland
Taranaki
Tasman
Waikato
Wellington
West Coast
Other
Region
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One Off
Up to 5 hours a week
Up to 10 hours a week
Up to 20 hours a week
Up to 30 hours a week
Up to 40 hours a week
What sort of time commitment would suit you? Ongoing or just one off work? How many hours per week?
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No
Yes
Please call me to discuss
Do you give permission for us to forward your name, contact details, and registration details to the Ministry of Health or other agencies if they approach us for candidates for volunteers?
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Next Page
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Thank you, we just need some more specific information...
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I am a doctor
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I am a medical student
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I am a health professional
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Doctors
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What m
edical qualification do you have what is the name of your university?
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Yes
No
Not Applicable
Do you hold a current Annual Practicing Certificate?
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Any notes the Annual Practicing Certificate
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What is your NZMC number?
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Do you have any Specialist qualifications? If so, please specify.
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Yes
No
Not Applicable
Do you hold current Indemnity Insurance?
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Do you speak any other languages? Please list them.
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Yes
No
Are you willing to help SVA in other ways?
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Additional General Notes
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Medical Students
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University of Auckland
University of Otago
Medical School (NZ)
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First Year
Second Year
Third Year
Fourth Year
Fifth Year
Trainee Intern
Year at medical school
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Yes
No
Not Applicable
Access to transport - Homeguard
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Full
Restricted
Learners
NZ Driver Licence
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Do you speak any other languages? Please list them.
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Yes
No
Are you willing to help SVA in other ways?
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Additional General Notes
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Other healthcare professionals
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Medical Profession
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Yes
No
Not Applicable
Do you hold a current Annual Practicing Certificate?
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Annual Practicing Certificate Number
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Any notes the Annual Practicing Certificate
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Do you speak any other languages? Please list them.
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Select...
Yes
No
Are you willing to help SVA in other ways?
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Additional General Notes
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Submit
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