First Name

Surname

Preferred Name

Address

Suburb

City

Postcode

Mobile Number

Email Address

Date of Birth

Gender

• Female
• Male
• Other

Which ethnicity do you identify with?

Which Iwi/s do you identify with?

Name of school, youth programme or community programme

If you are at school, what year are you in?

• Year 11 / NCEA level 1
• Year 12 / NCEA level 2
• Year 13 / NCEA level 3
• Employment or Training support
• Job seeker
• Not applicable

How did you hear about DINE Academy?

Teacher
Youth support person
Friend
Youth provider
Other (please state):

NSN Number

*IRD Number

*Date of registration

Please upload the following documents if you have them.
*If you don't have items in 'bold', these must be submitted asap.
Multiple files allowed. Maximum file size 2mb.

*CV

Cover Letter

*Passport or Birth Certificate

*Screenshot or Bank Statement of your Bank Account Number and Name

Drivers License

Programme code (class you registered onto e.g. DW171, DW172)

Uniform size

Preferred team (customer service or kitchen food preparation)

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Transportation

Driver's License?

• None
• Learners
• restricted
• Full

Type of License

Motor Vehicle
Motor Bike
Other (please state):

Do you have access to a vehicle?

• Yes
• No

How many people are in your immediate family?

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In case of Emergency, Please Contact:

Name

Relationship to you

Mobile Number

Land Line / Work Contact

Address

Suburb

City

Postcode

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Health and Wellbeing

Do you have learning support needs? e.g. Dyslexia, English as 2nd language, technology, literacy, numeracy etc

Do you have health/physical/wellness support needs? e.g. visual, hearing, physical impairment, claustrophobia etc

Do you have dietary requirements? e.g. gluten free, vegetarian, pescetarian, dairy free, nuts etc

Have you had a criminal conviction or trespass notice?

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Social Media:

Instagram

Facebook

Twitter

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Quick Questions:

1) Where would you like DINE to lead you over the next 6 months? (e.g. job, apprenticeship, customer service job)

2) Please list any goals you have in the next 3-5 years? (e.g. chefs apprenticeship, Barista, Own a Cafe or Restaurant)

3) What do your parents or carers do for a living?

Are you currently employed?

• Yes
• No

What is the highest qualification you have achieved? (e.g. NCEA level 1)

Are you currently receiving any kind of WINZ benefit?

• Yes
• No

Are you currently receiving any support from youth workers, support workers or medical professionals?

• Yes
• No

What do you want to achieve in your career?

On a scale of 1 to 7 how confident do you feel at the moment?

• 1 (Not very confident)
• 2
• 3
• 4
• 5
• 6
• 7 (Very confident)

Please upload a selfie :)

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By ticking this box I consent for Dine Academy, to use data, information, photographs, video footage, images and success stories, collected while participating in the Dine Academy Programme and other associated programmes, for the purposes of marketing, reporting, educational & research.

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By submitting this form, I agree to the Terms and Conditions