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Please fill out this form as completely as possible, the more information available about your facility - the more useful your record becomes to website users.

General Information

Facility Name :
Facility Abbreviated Name :
Address :
Town :
District (North, South, East, West, Nor-East, Sou-West...) :
Suburb :
Mobile Phone :
Phone :
Fax :
Main Contact Email :
Reminder Emails :
Reminder Email Carbon Copies :
Separate multiple email addresses with a comma character.
Daily CC
Village Reminder Emails :
If this field is blank, village reminders will be sent to "Reminder Emails" address
Review Notication Email :
If this field is blank, review notification emails will be sent to the "Main Contact Email" address
Info Pack Request Email :
Info Pack Request URL :
Redirect the user to the specified Info Pack Request URL
e.g. http://www.yoursite.co.nz/info_request_form
Eldernet / Agency Newsletter CC Emails :
Please enter one email address per line only.
Website :
e.g. http://www.eldernet.co.nz
Facebook URL:
e.g. http://www.facebook.com/profile.php?id=100002451830726
Respite Booking Request Email :
Receive non-essential Eldernet newsletters? :


Key Personnel

Manager :
Note: You must enter a value in the "title" field for these contacts to display


Username & Password

Please select a username and password, you must repeat your chosen password to ensure you do not mis-type.
Username :
Set Password :
Repeat Password :