*** 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. *** Department of Internal Affairs – Te Tari Taiwhenua BDM401 Application to record or update donor details on the Human Assisted Reproductive Register (Voluntary Scheme) Last updated 23 April 2024 Use this form if you: Have donated sperm, eggs or embryos to a fertility service provider before 22 August 2005 for use in assisted reproductive procedures, and Want to record or update your details on the Human Assisted Reproductive Technology (HART) Register. Part 1: Before you apply How to submit your application Complete and post to: HART team Births, Deaths and Marriages PO Box 1052 Wellington 6140 What you need to provide You will need to: • provide a certified true copy of an identity document • make a statutory declaration on page 6 of this form. Your identity document can be your driver licence or the photo page from your passport. A certified true copy is a photocopy that has been stamped or endorsed by an authorised person. This confirms that the copy is a true copy of the original document. A statutory declaration is a written statement signed in front of an authorised person and declared to be true. An authorised person must be: • a Justice of the Peace (JP) • a solicitor or notary public (you may have to pay for their services) • a Registrar or Deputy Registrar of the District Court or the High Court, or • authorised staff in some government agencies. You must present your current photo identification to the person authorised to take a statutory declaration when you sign the declaration in front of them. They can certify the photocopy of your photo identification at the same time. Services a counsellor can offer We recommend that you consult with a counsellor of your choice before submitting this form. A counsellor can: • help you to consider the implications of providing and accessing information • support you if you contact a donor-conceived person, if a link is established • 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. Linking your information with donor-conceived people’s information We 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. It is not compulsory to provide any of the information on this form. However, the more information that you provide, the more likely we can link your details with the details of donor-conceived people. The most important piece of information to provide is any identifying number or symbol used by the fertility service provider, if known. We will confirm your identifying number or symbol with the fertility service provider, to ensure it is accurate. It is important that you advise us of any changes to your information. This will ensure that: • we can advise you if a link is established to a donor-conceived person • accurate information about you can be provided to a donor-conceived person 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 information held about you on the register: • a person who the Registrar-General of Births, Deaths and Marriages believes to be a donor-conveived person related to you, if they are aged 18 or older (or aged 16 or 17 with the approval of the Family Court), or • a person who the Registrar-General of Births, Deaths and Marriages believes to be a guardian of a donor-conceived person related to you, if the donor-conceived person is aged under 18. You can request that access to the information in this form be restricted in certain ways on page 5. Restrictions can be added, removed or changed at any time. Part 2: Form begins How to answer: • You can complete this form by hand or on-screen using Adobe Acrobat Reader. • You can use the Tab key to move to the next fillable form field in Adobe Acrobat Reader. • You must still print off the application and sign by hand. • When you see this icon it means you need to take extra care with your answers. 1. Your application type New or updating ^ 2. Your name 2a. Current name Current first name(s) ^ Current surname ^ 2b. Name at birth (if different from above) First name(s) at birth ^ Surname at birth ^ 3. Your personal details Gender ^ Date of birth ^ Town or city of birth ^ Country of birth ^ Height in centimetres ^ Eye colour ^ Hair colour ^ 4. Your ethnicity and cultural affiliations Ethnicity ^ Cultural affilitation(s) ^ If Maori, whanau, hapu and iwi ^ 5. Your medical history Significant aspects of you and your immediate family’s medical history ^ 6. Your address Street number and name ^ Suburb ^ Town or city ^ Country ^ Postcode ^ Contact phone number ^ Email address ^ 7. Your reason(s) for donating ^ 8. Your fertility service provider information Name and branch of fertility service provider ^ Identifying number or symbol (if known) ^ 9. Restrictions on access to information What restrictions (if any) you want to be imposed on access to the information provided: Do not share my information with people conceived with my donations, Do not share that I’ve requested information about people conceived with my donations or Other (specify) ^ 10. Notification if a link is established If a link is established to the details of any donor-conceived people who are related to you, we can send you a notification if they supply their details. Do you want to be sent a notification if a link is established? Yes, or no ^ If yes fill in Section 11 If no go to the Section 12 statutory declaration 11. The address you would like any notifications sent to Deliver to the address from section 6? ^ Street number and name ^ Suburb ^ Town or city ^ Country ^ Postcode ^ Contact phone number ^ Email address ^ Statutory declaration You will need to sign this section in front of a person authorised to take a statutory declaration. 12. I, Full name ^ 13. of Enter your residential address. This cannot be a PO Box. Street number and name ^ Suburb ^ Town or city ^ Country ^ 14. a Enter your occupation. For example, bricklayer, teacher, unemployed. Occupation ^ 15. 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 Your signature ^ Date signed (dd/mm/yyyy) ^ Declared at (town or city and country) ^ Before (name of authorised person) ^ Qualification of authorised person ^ Signature of authorised person ^