Online Application

Student Information

Nominating School *

Nominating School is required

Level *

Level is required

Year *

Year is required

Student Name *

Student Name is required

Iwi *

Iwi is required

Student Photo *

Upload A File

Accepted file types: png, jpg, jpeg, docx, xlsx, pdf

Student Photo is required

Student Achievements

Please list the student’s achievements under one or several of the following headings:

Whakauru i te iwi whānui / Community or cultural involvement *

Community/Cultural Involvement is required

Te ārahina / Leadership *

Leadership is required

Mātauraka / Academic *

Academic is required

Hākinakina / Sporting *

Sporting is required

He kōrero tautoko anō / Other supporting information not previously covered

Mana Pounamu Young Achiever Recipient Testimonial

To be completed by the school principal or their nominee

Nominee Testimonial *

Nominee Testimonial is required

Nominee *

Nominee is required

Nominee Position *

Nominee Position is required

Mana Pounamu Young Achiever Recipient Whānau Endorsement

To be completed by a whānau member. Please tell us how wonderful your rakatahi is (include any information not previously covered).

Whanau Endorsement *

Whanau Endorsement is required

Endorser Name *

Endorser Name is required

Endorser Relationship *

Endorser Relationship is required

Mana Pounamu Media Consent

Thank you for agreeing to participate in future promotions of Mana Pounamu. We would appreciate you completing this form as an indication that you understand the purposes for which your image/statements/artwork/name, and/or profile will be used.

I give permission for Mana Pounamu to use my photo, artwork, name, and/or profile for promotional purposes, in a promotional video/CDRom, fliers, the world
wide web and in any other media items aimed at promoting Mana Pounamu, for a period of five years, unless otherwise stated. *

Media Consent Permission is required

Mana Pounamu will always use discretion when using video footage, my photo, artwork and/or profile and will not use it to discredit me in any way. *

Media Consent Discretion is required

I understand that I have the right to update or delete my file at any time. Once this request is made, it will be applicable to all future productions – all existing \
promotions will be continued to be used. *

Media Consent Update is required

I understand participants who are under 18 years of age have consent by their parent or guardian in accepting the above release. *

Media Consent Minor is required

Providers Details

Provider Name *

Provider Name is required

Provider Email *

Provider Email is required

Provider Phone

I agree that the information provided is correct. *

Information Correct is required