Sign up with plunket

If you would like to benefit from our services, please complete this enrolment form and we will be in touch with you shortly.

Services available through Plunket include:

• Plunket Nurse visits
• PlunketLine 0800 933 922 (a free telephone advice service)
• Car seat rentals
• Parent groups
• Parenting education
• Toy libraries

To find out how we manage your personal information, please see our privacy policy

New child information

Child's first name

Child's last name

Date of birth or expected due date*Please provide a valid date.

Ethnicity of child* Please choose... New Zealand European English Australian Dutch Other European Maori Samoan Cook Islands Maori Tongan Niuean Tokelauan Fijian Other Pacific Peoples Filipino Chinese Indian Japanese Korean Cambodian Other Asian Middle Eastern Latin American African Other please state: Please provide an ethnicity.

(Other - please specify)

Iwi/ hapū

Parent/caregiver information

Title

First name*Please provide a first name.

Last name*Please provide a last name.

Relationship to child*Please provide a relationship.

Ethnicity Please choose... New Zealand European English Australian Dutch Other European Maori Samoan Cook Islands Maori Tongan Niuean Tokelauan Fijian Other Pacific Peoples Filipino Chinese Indian Japanese Korean Cambodian Other Asian Middle Eastern Latin American African Other please state:

(Other - please specify)

Iwi/ hapū

Language(s)
(tick all that apply)

English	Maori	Samoan	Tongan
Cantonese	Mandarin	Other

Contact phone*Please provide a contact phone.

Mobile phone

Email address

Home address

Street*Please provide a street.

Suburb*Please provide a suburb.

City*Please provide city.

Postcode*Please provide a postcode.

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Plunket Area* Please choose... Auckland City Bay of Plenty Canterbury Counties Manukau Gisborne/Wairoa Hawke’s Bay Lakes Manawatu/Wanganui Mid-South Canterbury Nelson/Marlborough Northland Otago Southland Taranaki Waikato Waitemata Wellington/Wairarapa West coast Please provide a plunket area.

Postal address (if different)

Street/PO Box

Suburb

City

Postcode

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Additional information

Lead maternity carer (mid-wife/specialist)

National health index (NHI) number (if known)

Preferred method of communication*

Email Phone Post

Please provide your preferred method of communication.

Interested in finding more about
(tick all that apply)

Home and Clinic visits	Advocacy
Parenting education	Playgroups
Toy libraries	Parent support groups
Car seat rentals	Volunteer information

Future correspondence

I wish to receive future correspondence from Plunket regarding campaigns and sponsor promotions.*

Yes No

Please provide if you wish to receive future correspondence.

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