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Designated Caregiver (DCG) Agreement

International Students Indemnity Declaration for

Designated Caregiver (DCG)


A designated caregiver is a relative or close family friend designated in writing by a parent or legal guardian of an international student aged 10–11 years as the caregiver and accommodation provider for that student.

The designated caregiver will be subject to Waitākiri Primary School’s approval. Waitākiri Primary School is not responsible for the student’s care when the student is in the care of the designated caregiver.


  Student's name:

 (as in passport):


Preferred name:


New Zealand

arrival date:


New Zealand departure date:


Enrolment start date:


Enrolment end date:



I understand that the following conditions apply:


Waitākiri Primary School will:

  • visit the home of the caregiver/s before enrolment to determine that the living conditions are of an acceptable standard, and that the student will be supervised appropriately by the designated caregiver/s.
  • assess whether the caregiver/s will provide a safe physical and emotional environment for the student
  • require all people living in the home 17 years of age or over  to undertake a police vet before the application to enrol is accepted
  • determine that the accommodation is not a boarding establishment (i.e., does not have 4 or more international students staying in the home)
  • conduct sufficient interviews at school and visits to the home to monitor and review the quality of residential care, taking into consideration the age of the student, the length of the stay, and any other relevant factors.



Waitākiri Primary School will:

  • communicate regularly with the caregiver/s
  • ensure that the student has regular contact with their own family members (this is monitored by the designated caregiver and the school)
  • provide the student with access to a first language support person as required.



  • The student must be able to cope emotionally and socially and be willing to participate fully in family life and respect family routines, rules and expectations.
  • Waitākiri Primary School will review long-term placements after 6 weeks.
  • The enrolment may be terminated if the student is found to be unsuitable to live in a designated caregiver situation. Immigration will be notified if enrolment is terminated.
  • In a serious situation, Waitākiri Primary School may relocate a student immediately to alternative approved accommodation provided by the parents at their cost. If suitable alternative accommodation is not available, the enrolment will be terminated.

Waitākiri Primary School will:

  • act in the student’s best interests if there are any concerns regarding the welfare of the student
  • notify the student’s parents immediately about any concerns raised by school staff or the designated caregiver/s
  • refer serious matters to the relevant welfare agency.

Parents must:

  • notify the school immediately if they have any concerns about their child’s welfare.


Medical requirements

  • Parents must declare any behavioural or learning difficulties their child has on the enrolment form. Failure to do this may result in the termination of the enrolment, and the student could be returned home immediately at the cost of the parent/s.
  • Parents must declare any medical requirements their child has on the enrolment form. Failure to do this may result in the termination of the enrolment, and the student could be returned home immediately at the cost of the parent/s.
  • Waitākiri Primary School or the designated caregiver may request the student seeks medical advice and/or treatment and may arrange this. Any medical costs must be paid for by the student at the time in accordance with their medical insurance policy, or by other arrangement with the agent responsible for the enrolment, or parent/s in the home country.
  • Students who are unwell may not attend school. If a student is unwell, the designated caregiver is responsible for the care of the student. If the student becomes very unwell it may be necessary to terminate the enrolment, and for the student to return home.
  • All medications must be given to the designated caregiver/s on arrival, and administered only as required by an approved adult.


 Accidents and emergencies

  • The designated caregiver is responsible for seeing that all appropriate measures are followed in the case of emergencies or accidents during and outside school hours.
  • In the event of an accident or emergency, appropriate action will be taken and the student’s parents will be contacted as soon as possible by the designated caregiver, Waitākiri Primary School, or your agent. The principal or international coordinator responsible for international students must be notified immediately.
  • If the student has an accident, Waitākiri Primary School or the designated caregiver/s may need to consent to urgent medical procedures on behalf of the student’s parents, including blood transfusions if necessary.


Parents’ Declaration

  • I designate the person named below to provide accommodation, care, and support for my child to attend Waitākiri Primary School, in accordance with the Education (Pastoral Care of International Students) Code of Practice 2016, subject to the approval of Waitākiri Primary School.
  • I confirm that the person(s) nominated as the designated caregiver(s) is/are a ‘bona fide’ relative or close family friend. Proof of this relationship must be provided. I agree that this caregiver must be approved before the application to enrol at Waitākiri Primary School is accepted.
  • I understand that Waitākiri Primary School will make every effort to ensure the safety and welfare of my child while they are enrolled at the school.
  • I believe that my child will be able to cope with the cultural adjustment as well as being away from home.
  • I will take full responsibility and accept the decisions made by the designated caregiver/s about the day-to-day care of my child.
  • I believe our child will be polite and respectful in the designated caregiver’s home, and will make every effort to join in.
  • I will pay for any additional school costs promptly as they arise.
  • I will notify the school immediately if any conditions in this declaration change.

Designated caregiver’s name:






Parent’s name (1):


Relationship to child:



Parent’s signature (1):





Parent’s name (2):


Relationship to child:



Parent’s signature (2):






Parents’ home country address:






Parents’ email address:


Home country phone number:



Designated Caregiver’s Declaration

  • I am willing to take full responsibility for the care and welfare of the student named above while they are in New Zealand, including school holidays.
  • I confirm that all people living in the home are willing to be police vetted before the student’s enrolment application is accepted.
  • I agree that a representative from Waitākiri Primary School may visit my home twice a year, or as required.
  • I agree to support Waitākiri Primary School and be responsible for the student’s attendance.
  • I agree to inform the school about any emergency situations as soon as possible.
  • I agree to notify Waitākiri Primary School about any changes in circumstances.


Designated caregiver's name:


Designated caregiver’s signature:




Home phone:


Cell phone:






Home address:






Relationship to student:

(please provide proof)




New Zealand citizen/resident:



If NOT a New Zealand citizen/resident:

Passport number:


Visa type:




Visa expiry:






Witness’ name:




Witness’ signature:





Waitākiri Primary School has agreed to observe and be bound by the Code of Practice for the Pastoral Care of International Students published by the New Zealand Qualifications Authority (NZQA). Copies of the Code are available on request from this institution or from the NZQA website International Students section.