Test Universal Registration

I (carer) provide help with (please tick all that apply)*

Cared for Name*

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemaleNon-BinaryPrefer not to say

Details of long term condition/illness or disability*

Does the cared for live with you?*

YesNo

Address*

First line of address

Address 2*

TownPost Code

Is there something specific that you(carer) would like to talk to us about?

Here are some of the ways we can provide information - choose your preferred method(s)

If you wish to get involved and have your say, please select from the following option(s)

I would like to find out more about the Carer ForumI would like to find out more about the Parent Carer ForumI cannot commit any time at present but would like to be added to Facebook forum page to have my sayI would like to find out more about the Recognition to Rights TrainingI would like to explore volunteering opportunities with NLCTI would like to be added to your electronic mailing list

To provide you with the most appropriate information and advice, we may ask you for details of your caring role and the person(s) you care for.

Any information you provide will be processed in line with all relevant data protection legislation and laws.

If you consent to us processing and storing your personal details, we will never share them with third parties unless you give express permission for us to do so.

You can withdraw this permission at any time.

If you are making this referral on behalf of another person, please ensure that you have sought their consent to contact us and confirmed that you have explained how North Lanarkshire Carers Together will store and use this information.

Our usual communication methods with you are via email, phone calls and by post if necessary.

Do you consent to North Lanarkshire Carers Together using these methods to contact you?

Our full data protection and privacy policy is available at www.carerstogether.org

Do you consent to North Lanarkshire Carers Together storing and processing your personal information?*

YesNo

Print Name and date form completed*

Full NameDate

Thank you for registering with North Lanarkshire Carers Together! We are thrilled to have you join our community. For more information about our services, resources, and support for carers, please visit our website at North Lanarkshire Carers Together.

www.carerstogether.org

Carer details

Cared For Details

At NLCT, we are dedicated to creating meaningful opportunities for Carers to engage and participate in shaping the services and policies that impact your lives.

Data Protection and your privacy