Young Carer Registration Form

Young Carer Registration Form

Fill out the form carefully for registration.
Young Carer's Personal Information
Firstname:*
Lastname:*
Todays Date:

DayMonthYear
Todays Date:
Date of Birth:*

DayMonthYear
Age:*
Gender:*
Street Address Line 1:*
Street Address Line 2:
Town/City:*
County:*
Eircode Young Carers:*
Email:*

Confirmation EmailPlease enter a valid email address.
Mobile Number:*
Please enter a valid mobile number.

Parental Consent

This section must be completed by the parent/legal guardian of a young carer under the age of 18 years. A member the Young Carer Team will contact the parent by phone to verify that they gave their consent.
If you are aged 18 years or under, the following section must be completed by your parent/legal guardian.
Parent's Firstname:*
Parent's Lastname:*
Parent's Address:*
Street Address Line 2
Town/City*
County*
Eircode*
Eircode
Parent's Email:*

Confirmation EmailPlease enter a valid email address
Parent's Mobile:*
Please enter a valid phone number.
Parent's preferred means of contact*
Due to GDPR, and Child Safeguarding legislation, young people under the age of 18 can only use our service with parental consent.

Parental Consent

We/I give permission for the young person named above to register with Family Carers Ireland as a member and/or to participate in their Young Carers' Service.

We/I give permission for this young person to provide a photograph for the purpose of registering for a Young Carer Card (if applicable).

We/I have read and agree to Family Carers Ireland's privacy policy.

Parent/Guardian, on behalf of the young person:

We/I understand the personal data on this form will be used by Family Carers Ireland for the purpose of their registration, and for any necessary contact on behalf of the Young Carer Service.

We/I understand that the personal data will be retained by Family Carers Ireland for such period period as the young person is a member or is using the service.

We/I understand that we/I can withdraw this young person from the service by writing to youngcarers@familycarers.ie, and their personal data will then be erased.

We/I understand that if I do not provide the young person`s personal data they cannot use our service.

We/I understand that a copy of Family Carers Ireland’s Safeguarding Statement can be accessed through my local Family Carers Ireland Support Centre or by emailing youngcarers@familycarers.ie.
Parent's Signature:*

Clear
Date Signed:*

DayMonthYear
Enter today's date

Young Person's Consent
I, consent to registering with Family Carers Ireland’s Young Carers Service as a member and/or service user.

I consent to providing a photograph for the purpose of registering for a Young Carer Card (if applicable).

I have read and agree to Family Carers Ireland's privacy policy.

I understand the personal data on this form will be used by Family Carers Ireland for the purpose of my registration, and for any necessary contact on behalf of the Young Carers Service.

I understand that the personal data will be retained by Family Carers Ireland for such period as I am a member or using the service and for 12 months thereafter unless I request for my personal data to be erased by emailing youngcarers@familycarers.ie.

I understand that I can cancel my mebership and/or withdraw from the service at any time by writing to youngcarers@familycarers.ie, and my personal data will then be erased.

I understand that if I do not provide consent that I cannot become a member and/or use the service.

I understand that a copy of Family Carers Ireland’s Safeguarding Statement can be accessed by emailing youngcarers@familycarers.ie.
Preferred means of contact*
Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

Young Carer Registration Form

Young Carer's Personal Information

Your Young Carer Service

Caring Role

Parental Consent

Young Person's Consent