*** Transcriber's Note: Please set your voice synthesiser to read most punctuation. When you encounter the caret sign at the end of a line, please enter the applicable information, if necessary. *** 
Internal Affairs Te Tari Taiwhenua

BDM401

Application to Record (or Update) Donor Details on the Human Assisted Reproductive Technology Register (Voluntary Scheme).

When to use this form.
This form collects information about people who donated sperm, eggs or embryos to a fertility service provider before 22 August 2005 for use in assisted reproductive procedures.

Linking donor offspring and donor information.
Births, Deaths and Marriages will use the information on this form to establish a link to the details of the people who were born as a result of your donation (“donor offspring”). It is not compulsory to provide any of the information on this form, but the more specific information that you provide, the more likely a link can be made with the details of donor offspring. The most important piece of information to provide is any identifying number or symbol used by the fertility service provider (if that is available). Births, Deaths and Marriages will confirm that number/symbol with the fertility service provider, to ensure it is accurate.

It is important that you advise Births, Deaths and Marriages of any changes to your information. This will ensure that Births, Deaths and Marriages can advise you if a link is established to donor offspring, and that accurate information about you can be provided to donor offspring when they request it.

Restrictions on access to the information.
The information on this form is collected and held by Births, Deaths and Marriages. Access to the information will be provided in accordance with the Human Assisted Reproductive Technology Act 2004. Fees apply to the provision of registered information, or for providing confirmation that any information is held by Births, Deaths and Marriages. You can apply to access the information held by Births, Deaths and Marriages about you. 
The following people can also apply to access that information:
•a person whom the Registrar-General of Births, Deaths and Marriages believes to be a donor offspring related to you, if aged 18 or older (or, if 16 or 17, with the approval of the Family Court); or
• a person whom the Registrar-General of Births, Deaths and Marriages believes to be a guardian of a donor offspring related to you, if the donor offspring is under 18.

You can request that access to the information in this form be restricted in certain ways. There is a space on the form for you to describe the restrictions that you want to apply. Restrictions can be added, removed or changed at any time. 

Benefit of counselling.
It is strongly recommended that you consult with a counsellor of your choice before submitting this form. Counselling helps people to consider the implications of providing and accessing information, and contacting a donor offspring if a link is established. Counsellors can answer questions about how others have approached the issue, and what seems to work best. Counselling may be able to be arranged through your fertility service provider, or with an independent counsellor.

Please complete and post to 
HART Team, 
Births, Deaths & Marriages (HART), PO Box 10526, Wellington 6143.

Please attach a certified copy of an identity document of yours e.g. driver licence or birth 
certificate or the bio-data page from your passport. 

Please indicate Registration Type? 
New. Yes or No ^
or Updating. Yes or No ^

Personal Details of Donor.
Current first name(s) ^
Current surname ^
First name(s) at birth (if different from above) ^
Surname at birth (if different from above) ^
Gender ^
Date of birth ^
Place of birth ^
Country of birth ^
Height (in centimetres) ^
Eye colour ^
Hair colour ^
Ethnicity ^
Cultural affiliation(s)(if any) ^
If Maori, please state (if known)
Whanau ^
Hapu ^
Iwi ^

Aspects of your and your immediate family’s medical history, if significant.
You: ^
Your mother: ^
Your father: ^
Your grandparents: ^
Your children: ^
Your siblings: ^

Reason(s) for donating.
You may state here the reason(s) why you donated. ^

Fertility Service Provider Information relating to Donor. 
Name (and branch) of fertility service provider(s) ^
Donor identifier (if available) ^

Your Current Address Details. 
Flat number (if applicable) ^
Street number & name ^
Suburb or rural locality ^
City, town or district ^
Country (if not New Zealand) ^
Phone number ^
Email address ^

Restrictions on Access to the Information.
Please state what restrictions (if any) you want to be imposed on access to the information provided. ^ 

Notification if a link is established. 
Births, Deaths and Marriages can advise you if a link is established to the details of one or more donor offspring who are related to you, where those people supply their details. This advice will be provided in a letter to you. Do you want to be advised if a link is established? 
Please circle Yes or No ^

If yes, please state the address for the letter. ^

STATUTORY DECLARATION. (Please complete this part in front of a person who is authorised to take statutory declarations).
I, Full name ^
of Full residential address ^
Occupation ^
solemnly and sincerely declare that the information provided in this application is true. And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957. 

Signature of person making declaration ^

Declared at 
Place ^
this day (DD/MM/YYYY) ^
before me: ^
Registrar of Births, Deaths and Marriages, or Barrister and Solicitor of the High Court of New Zealand, or Justice of the Peace, or Notary Public, or other person who is authorised to take statutory declarations.