ADHD Youth Coach Programme

Application for Enrolment & Consent

ADDventurers ADHD Support is an initiative of The Runway Foundation
www.therunwayfoundation.org.nz

Introduction to The Runway Foundation:

The Runway Foundation is a registered not-for-profit organisation in Pukekohe that is funded
privately, through donations and fundraising. The Runway Foundation in good faith desire and
aim to support our ADHD community and are not benefitting financially in any way by providing
these services. We are not specialists or experts in ADHD services, however, aim to gather
together a wide range of experience and collective knowledge through the collaboration of our
staff, professional services, and our ADHD community. Together we create a strong network
of support for each other.

Application Date: ________________________________

Student’s Details:
Name: _________________________________________ Date of birth: _______________
Age: ____________________________ School Year: ____________________________
School Name: _______________________________________________________________
Email: _____________________________________________________________________

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Mob: ______________________________________________________________________
Address: ___________________________________________________________________

Parent’s Details:
Name: _____________________________________________________________________
Email: ______________________________________________________________________
Mob: ______________________________________________________________________
Address (if different from above): _______________________________________________

Emergency Contact Details (if different from parent’s details):

Name: ________________________________ Mob: ____________________________
Relationship to student: _______________________________________________________

Nominated Contact for any additional permissions (if different from above):
Name: ________________________________ Mob: ____________________________
Email: ___________________________ Relationship to student: _____________________

Please disclose any medical conditions, allergies, fears, or emotional concerns that your
child has. The more the Runway Youth Coach understands your child, the greater support
they can provide.

1. Has your child been professionally diagnosed with ADHD? ________________________

2. Through which registered specialist were they diagnosed? _______________________
3. Is Your child currently on medication for ADHD? Please Name: _____________________
4. Does your child have other medical or mental health conditions? Please name and note
as mild, moderate or severe:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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5. Does your child have any allergies / food intolerances / dietary requirements?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

6. What are your child’s fears, or emotional concerns?

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

7. Are there any other behaviour traits that are helpful to be aware of?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

8. Please list any known causes that trigger negative emotions / behaviours / resistance /
other frustrations:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

9. Referring to Q.8, what actions / responses / medications are then required?

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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10. If your child experiences a period of frustration / meltdown how do they calm themselves?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

11. Does your child have any balance, coordination, sensory needs or physical challenges? If
yes, what?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

12. My child has the following areas of interest:

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Declaration:
I declare that all the above information is accurate to the best of my knowledge and I
consent to my son / daughter participating in the Runway Youth Coach programme.
I understand that:
• The Youth Coach is there to provide emotional support and guidance while enrolled
in school, and to advocate for my child with teachers and other support services,
being their ‘voice’ when they are unable to speak for themselves. This does not
include or replace professional counselling or any other type of specialised health
sector service.

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 • The Youth Coach will consult with caregivers, teachers and other relevant support
services regarding my child, and information relating to my child’s wellbeing may be
shared with the Youth Coach (and vice versa), for them to provide an individual
mentoring programme that is informed and considerate of their needs, and always
in the best interest of my child.
• The individualised programme will be created with my child, based on their personal
and educational goals.
• The time spent enrolled in the programme will be dependent on my child’s needs
and only while your child wishes to do so.
• Initially my child will only meet with the ADDventurers Youth Coach during school
hours, at their school, as advised by the teachers concerned and with school
permission. Once my child is on the Youth programme an Individual Plan will be
developed for my child, outlining further activities on the programme that will help
them to achieve their goals. This plan will be emailed to me, and I will read the plan,
discuss any concerns and provide approval for the plan once mutually agreeable.
• All personal information on this form and gathered during the Youth Coach
programme is confidential and used only for the purposes stated on this form.
• The ADDventurers Youth Coaches have been safety checked for working with
children in accordance with The Vulnerable Children’s Act of 2014.
• I have the right to withdraw my child from this programme at any time, with written
notification, and view any information that is recorded regarding my child.
• I am the legal guardian of the applicant of this programme and have the legal right to
provide consent for the above.
• I agree to contribute towards the cost of the Youth Coach Programme, or to request
an exemption from fees due to financial hardship. At the time of writing this the
fees are $50 per term.
• I consent to my child having their photo taken for identification and use for Runway
Board and Charities Commission Reporting purposes. I am also happy for the
photo’s taken at ADDventurers group activities that include my child, to be used for
the Runway newsletters, and shared within the closed Facebook, Instagram or
WhatsApp groups for student’s and their family to see. At times we may request

ADDventurers Youth Coach Programme Enrolment & Consent Form. RA7. 30.03.21 5
 your permission, or your child’ permission if over 16 years, for photo’s to be used for
promotional purposes.

Name: __________________________________ Signed: ___________________________

Date: _________________

All information is held in confidence and will be available only to those directly involved with your child’s care and
supervision.
Our staff are Police Vetted.

Please feel free to contact our Youth Programme enrolment co-ordinator:

mellissa@runway.net.nz if you have any concerns or questions regarding the
programme and the consents. You are welcome to fill out this application, and leave
it unsigned until your son or daughter have been offered a place on the programme
and you have all of the information that you need.
Please refer to the application process diagram below for information on our
enrolment process.
Thank you for working with us on this process to ensure we can do our best for your
child.

Once filled out, please return it to mellissa@runway.net.nz, or drop it into / post it to

The Runway Foundation, 58 Glasgow Road, Pukekohe.

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ADDventurers Youth Coach Programme Enrolment & Consent Form. RA7. 30.03.21 7