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THE HOUSE OF GRACE ENQUIRY
If you want to know more about living at The House of Grace, please fill out a few details below.
We will also automatically send you information about living at The House of Grace and a link to apply if you want to do that now. Please check your 'junk' email folder if you don't receive anything.
What is your email address?
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This is the email address we will send the application link to
Confirm What is your email address?
Please tell us how you heard about The House of Grace:
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Church/Church group
DHB Services
Friend
Internet
Midwife
Other
Poster - Mall / WINZ
Referring Organisation
Social Media
Social Worker
Teen Parent Unit or School
Please tell us why you are interested in the home:
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Are there any additional details that would be helpful for us to know:
Referral agency (if applicable)
Referrer's name
Referrer's number
Young person's details
Name
First name
Last name
Age
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Phone number
Ethnicity
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Asian
Australian
Chinese
English
European
European/Asian
European/Indian
European/Maori
European/Maori/Samoan
European/South African
European;Maori
Maori
Maori;NZ pakeha
NZ European
Other
Pacific Islander
Papuan/ Kiwi
Russian
Samoan
Samoan/NZ'er
South African
Sri Lanken
Turkish/European
Unknown
Due date or babys DOB
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If you are unsure please put an estimated date
Current city/town
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The information I have given is true and correct
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Yes
* You can view our privacy statement on The House of Grace website: www.thehouseofgrace.org.nz to find out how we manage your personal information *
Please check the highlighted fields
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