TextMATCH TextMATCH Registration form We do not store any IP addresses for those submitting this form. Step 1 of 3 33% Please check whether you are eligible to enrol*Eligibility criteria You are eligible for this programme if you are: • pregnant or have a newborn baby • live within the ADHB or WDHB catchment areas • you or your baby identify as Maori, Pasifika, Asian (Chinese, Japanese, Korean) or South Asian. I am eligible to enrolPlease read the privacy statement*Privacy Statement We collect personal information from you, including your: • Name • Suburb • Mobile number • Your relationship to the baby • ethnicity • language preference • baby's estimated due date • baby's birth date, name, gender for the TextMATCH birth to 2 program We collect your personal information in order to personalize the TextMATCH program. We share this information with: • National Institute of Health Innovation (NIHI), University of Auckland, for delivery of the TextMatch program • Ministry of Health for funding and reporting requirements If you choose not to enter information, we will not be able to process your enrolment. Once you complete this form it will be sent by email to NIHI for enrolment. You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. If you would like to ask for a copy of your information or to have it corrected, please contact the manager Elaine Umali firstname.lastname@example.org I agree to the privacy statement. Name* First names are used in some TextMATCH messagesMobile Number* TextMATCH messages are sent to this phoneSuburb* Some TextMATCH messages are specific to the Waitematā and Auckland regions only. If you live outside these regions, your enrolment will depend on availability. Your relationship to baby* Mum Dad Ethnicity*Select your ethnicityMāoriSamoanFijianCook Island MāoriChineseKoreanJapaneseTahitianEnglishNiueanTuvaluanTonganAfghanistanBangladeshiFijian IndianIndianNepalesePakistaniSri LankanTextMATCH is funded for certain ethnicities due to culture and language differences. This information is used for reporting purposes.Language*Select your languageTe reoChineseJapaneseKoreanEnglishTextMATCH messages will be in either of these languages. Some messages may include cultural greetings even when English is chosen i.e. Kia ora, Bula, etc. Which TextMATCH programme would you like to enrol in?* Pregnancy Birth to 2 years old Each program is a series of health messages designed for pregnancy or baby's developmental stages.What is the estimated due date for baby?* DD slash MM slash YYYY TextMATCH messages are suited to baby's development, the due date ensures you receive the correct messages at the right timeWhat is your child's date of birth?* DD slash MM slash YYYY Only children under 21 months can register for TextMATCH. The TextMATCH messages are suited to baby's development, the birth date ensures you receive the correct messages at the right timeWhat is your child's name?* What is your child's gender?* Male Female Promotion activity*How did you hear about TextMATCH?Healthy Babies WebsiteFacebook AdveritisementCommunity Partnership GrantStaff @ HealthWESTStaff @ The Asian Network IncStaff @ The FONOStaff @ CNSSTEvaluation* YES NO May we contact you for feedback?Consent to send your information* Yes I consent No I do not consent Do you consent to your information being sent to the National Institute of Health Information (NIHI) for TextMATCH enrolment?NameThis field is for validation purposes and should be left unchanged.