MAGIC NZ Supporting Children with Growth Disorders and their Families Membership Application Parent Name/s: Address: City: Email: Phone: (home) (work) (mobile)

www.magicnz.org.nz

Occupation and ethnicity details are collected for statistical purposes only.   This information will only be used as part of collective data about membership of MAGIC NZ.
Child's Name:	Date of Birth:	Gender: Male/Female
Sibling Name:	Date of Birth:	Gender: Male/Female
Sibling Name:	Date of Birth:	Gender: Male/Female

Type of Membership

Active

Friend

Donation:		$10		$25		$50		Other ________

MAGIC NZ does not charge a membership fee to ensure no one is excluded. We operate through fundraising, grants and donations. If you would like to make a donation, you will be helping us to extend our services.
 

Please make cheques payable to:		The MAGIC Foundation NZ
And send to:		The Treasurer, PO Box 1493, Wellington, NZ

Networking

We do not wish to participate in the networking programme at this time.

This networking information allows MAGIC NZ to match you to other families, within New Zealand and internationally, who have a child with the same or similar condition/health issues as your child.  MAGIC NZ takes the protection of your private information very seriously and will not release any information to any person/organization not affiliated to MAGIC NZ.

Child's disorder/syndrome/growth disorder: (e.g. growth hormone deficiency, thyroid deficiency, Turner's, nutritional, RSS, SGA, MAS or undiagnosed) There are numerous disorders. Please be as specific as possible.

If possible, explain your child's health issues in more detail, including medications. List any secondary conditions or problems your child has: (e.g. asthma, allergies, learning disorders, eyeglasses, etc., including additional medications).   Use back of sheet.

I give permission to release my name, address, phone, email and primary disorder/illness of my child to families facing a similar situation who are interested in communicating. Releasing specific information regarding your child will be at the discretion of the interacting families.

Signed:___________________________________

Date:______________

Statement of Purpose:

The MAGIC Foundation NZ (MAGIC NZ) is a not-for-profit organization dedicated to supporting the families of children with chronic and/or critical disorders, syndromes, diseases or other issues that affect their growth.
We achieve this through:

• Educating parents, children, healthcare professionals, teachers, and the public about the specific needs and matters impacting our children’s social, physical and emotional development;
• Networking NZ families with each other and with the global community; and
• Advocating for better medical and psychological outcomes for our children.

Privacy statement:   Privacy Act 1993:   This information is collected for the purpose of membership in MAGIC NZ. It will remain confidential to MAGIC NZ