Carers register form
Please complete this form to be put on our carers register. We will use this register to support you the best we can and issue quarterly newsletters with current information and advice.
How we will use your information
The information you provide in this application will be used to add you to our carers register. We may also use anonymised information for monitoring, reporting, and service improvement purposes. Your personal information will be stored securely and handled in accordance with data protection legislation.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
Town
State / Province
Postcode
Date of Birth
*
/
Day
/
Month
Year
Date
Email
*
example@example.com
Phone Number
*
Alternative Contact Number
Please tell us the name of the person you are caring for:
*
Please tell us the date of birth of the person receiving care:
*
/
Day
/
Month
Year
Date
What is your relationship to the person you care for?
*
Does the cared for person live with you? Yes/ No. If no, please state where they live (e.g. alone, in sheltered accommodation, or other (please state) and whether they receive any paid care and support in their home.)
*
Please provide the cared for persons address:
*
Street Address
Street Address Line 2
Town
State / Province
Postcode
Please name the health condition(s) of the cared for person (e.g. Dementia, Autism):
*
Please provide details about the type of care you provide (help with personal care, help with shopping, domestic tasks, etc.)
*
How long have you been providing care for this person?
*
How many hours a week do you provide care for this person?
*
Do you feel you know your rights as a carer?
*
Yes
No
Unsure
Please let us know from the options below what sort of support you would be interested in from us.
*
Drop-in information sessions
Coffee mornings/afternoons
Online training about your legal rights as a carer
Assistance with filling out forms
Other
What kind of activities or services would you like to take part in?
*
Where did you hear about the carers register?
*
Directly from us
Word of mouth
Online search
Social media
Other
Is there anything else you would like us to know?
Signature
*
Continue
Continue
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