Registration | Moriori Imi Settlement Trust

Section 1: Personal Details

Title

First Name:*

Middle Name(s):

Surname:*

Surname at Birth (if different):

Preferred Name:

Date of Birth:*

Place of Birth:

Occupation:

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Registration Number

If you are a member of Hokotehi Moriori Trust (HMT), please provide your registration number (which you hereby consent may be used for hokokpapa verification purposes):

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Not existing member

If you are not an existing member of HMT, please tick here if you would like HMT to contact you regarding membership registration with them also. (Note: if consent is provided here, we will only share your name and contact details with HMT.)

Section 2: Contact Details

Email Address:

Important: If you are providing an email address, please ensure it is unique to you as this will be used to send individual communications relating to your membership only, otherwise communications will be sent by post.

Primary Phone Number:

Other Phone Number:

PHYSICAL ADDRESS:*

Address Line 1: Address Line 2 Town/City: Region: Post Code: Country

Different Mailing Address

MAILING ADDRESS (if different):

Address Line 1: Address Line 2 Town/City: Region: Post Code: Country

Please note that every adult registered member will receive important emails and correspondence relating to membership and individual registration matters, including notifications of meetings and elections.

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Not existing member

Tick here if you would also like to subscribe to the Moriori Imi Settlement Trust email marketing list (to receive news and updates about MIST’s activities, advice about upcoming events and other relevant but non-critical communication).

Section 3: Children’s Details

Please provide details if you have a child or children (17 years or younger).

Child #1 Name:

Child #1 Date of Birth:

Child #2 Name:

Child #2 Date of Birth:

Child #3 Name:

Child #3 Date of Birth:

Child #4 Name:

Child #4 Date of Birth:

Child #5 Name:

Child #5 Date of Birth:

Child #6 Name:

Child #6 Date of Birth:

Child #7 Name:

Child #7 Date of Birth:

Child #8 Name:

Child #8 Date of Birth:

Child #9 Name:

Child #9 Date of Birth:

Child #10 Name:

Child #10 Date of Birth:

Extra Space if Needed:

Section 4: Hokopapa

We need to trace your Moriori descent back to the karāpuna/ancestor(s) named in the application. Only your Moriori hokopapa needs to be provided.

Are you legally adopted/whāngai?:

Yes

No

I am a descendant of the following Moriori karāpuna/ancestor(s):

Is your father, mother or both parents of Moriori descent?

Father

Mother

Both

Father’s Hokopapa

Father’s Name:

Paternal Grandfather

Grandfather

Paternal Grandfather’s Father

Great-Grandfather

Paternal Grandfather’s Mother

Great-Grandmother

Paternal Grandmother

Grandmother

Paternal Grandmother’s Father

Great-Grandfather

Paternal Grandmother’s Mother

Great-Grandmother

Extra Space if Needed:

Mother’s Hokopapa

Mother’s Name:

Maternal Grandfather

Grandfather

Maternal Grandfather’s Father

Great-Grandfather

Maternal Grandfather’s Mother

Great-Grandmother

Maternal Grandmother

Grandmother

Maternal Grandmother's Father

Great-Grandfather

Maternal Grandmother’s Mother

Great-Grandmother

Extra Space if Needed:

Section 5: Statement

I declare the information submitted in this registration form is true and correct and that:

1.I wish to apply to become a registered member of Moriori Imi Settlement Trust.
2.I confirm my line of descent is through the bloodline detailed in this application, or I was legally adopted/whāngai to my parent(s) who are of Moriori blood descent.
3.I am over 18 years old or my parent/legal guardian is consenting to this application below.
4.I have submitted evidence (or will submit further evidence if requested) of my hokopapa (genealogy), and understand this may be required by the Hokopapa Unit for the process of validating my application for registration. The Hokopapa Unit may also ask for verification of identity.
5.I understand that my children listed in this application, or who I may request to be added to my record at a later date, will automatically be registered as adult members on their 18th birthday. MIST will send a notification around the time of their birthday advising them of their registration number and other membership information.
6.I consent to this information being held on the Moriori Imi Settlement Trust database and used only for Moriori Imi Settlement Trust purposes.
7.I acknowledge that failure to complete all sections of this registration form truthfully may render this registration invalid.
8.I will endeavour to keep my contact details up-to-date at all times.
9.I acknowledge that I may withdraw my registration at any time by notifying Moriori Imi Settlement Trust accordingly.

Yes, I understand the terms and policies.*

Tick here to confirm you have read and agree with the above statement

Tick here if you are applying on behalf of a child, and provide the following information:

Tick here if you are applying on behalf of a child and provide the following information.

Full Name:

Contact Details (phone/email):

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Signature*

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Date:*

Privacy Act 2020:

The information that you supply on this registration form will be held in the Moriori Imi Settlement Trust database and will be subject to rules of access. No information will be disclosed to third parties without your express permission. You have a right to access your personal information held by Moriori Imi Settlement Trust upon request by you and make any appropriate corrections to that information to ensure that the information held is accurate.

Communication:

Notices of elections, annual general meetings and special meetings will be communicated directly and via our website and social media channels.

Application to Become a Registered Member of Moriori Imi Settlement Trust

Section 1: Personal Details

Section 2: Contact Details

Section 3: Children’s Details

Section 4: Hokopapa

Father’s Hokopapa

Paternal Grandfather

Paternal Grandmother

Mother’s Hokopapa

Maternal Grandfather

Maternal Grandmother

Section 5: Statement