In accordance with the General Data Protecon Regulaon 2018 (GDPR) the informaon that you provide on this registraon form
will be entered into a secure, password protected database and the paper copy will be held in a locked ling cabinet. We collect and
process informaon about you in order for us to be able to support your needs as a carer, for example by helping you with forms or
referring you to another organisaon for advice. Please ask for our Privacy Statement for more informaon about how we collect
and process data.
Please ck which of the following publicaons you would like to receive:
Please ck all that apply:
Monthly e-bullen (What’s New for Carers) available by email only
Quarterly newsleer (Carers News) by email by post by post and email
Other important updates and events for carers available by email only
Informaon pack for carers
Consent - please sign below
I am a carer and I give consent for the Carers Informaon Service to collect and process my informaon, in accordance with the
General Data Protecon Regulaon 2018 (GDPR) and the Carers Informaon Service Privacy Statement.
First name Last name
Signature Date
Third Party Consent
I have the consent of the carer to complete this form on their behalf.
First name Last name
Signature Date
Please complete this form in BLOCK CAPITALS. Fields indicated * are mandatory, all others are oponal.
YOUR DETAILS
Title First name* Last name*
Address*
Postcode*
Tel: Home Tel: Work
Tel: Mobile
Email Address
Gender Date of Birth*
____ / ____ / _______
First Language
Name of doctors surgery Disability or health concerns
Carers’
Registration Form
RELATIONSHIP TO PERSON YOU CARE FOR*
My husband/wife/partner My parent My sibling My child under 18
My child over 18 My brother or sister Another family member My friend
How long have you been a carer?
How many hours per week do you spend as a carer?
ETHNICITY (PLEASE TICK)
Asian Indian
Black Brish
Mixed White/Black Caribbean
White Brish
Arab
Asian Pakistani
Black Caribbean
Mixed White/Black African
White Irish
Asian Bangladeshi
Black African
Mixed White/Asian
White Gypsy/Traveller
Chinese
Other Black
Other Mixed
Other White
Other Asian
Other (please state)
No wish to reply
DETAILS OF PERSON YOU CARE FOR
Title First name
Last name Date of Birth ____ / ____ / _______
DISABILITY OR HEALTH CONCERNS (PLEASE TICK)
ausc spectrum disorder Alzheimers / demena blind/visual Impairment cancer
deaf/hearing impairment dual sensory impairment elderly/frail epilepsy
HIV/AIDS learning disability long-term health condion palliave care
mental health problem MS Parkinson’s disease physical disability
stroke substance addicon wheelchair user
other (give details)
ETHNICITY (PLEASE TICK)
Asian Indian
Black Brish
Mixed White/Black Caribbean
White Brish
Arab
Asian Pakistani
Black Caribbean
Mixed White/Black African
White Irish
Asian Bangladeshi
Black African
Mixed White/Asian
White Gypsy/Traveller
Chinese
Other Black
Other Mixed
Other White
Other Asian
Other (please state)
No wish to reply
IF YOU CARE FOR MORE THAN ONE PERSON PLEASE GIVE FURTHER DETAILS BELOW
HOW DID YOU HEAR ABOUT THE CARERS INFORMATION SERVICE/CARERS SUPPORT CENTRE?
Passerby Word of mouth Internet search engine
Health Professional (please state)
Social Care Professional (please state)
Voluntary/Community Organisaon (please state)
Carers Informaon Service/Carers Support Centre Publicity (please specify):
Poster Leaet Website Newsleer E-bullen Social media
Don’t know Other (please state)
Carers Information Service, Carers Support Centre, 24 George Street, Croydon CR0 1PB
020 8649 9339 (option 1) info@carersinfo.org.uk carersinfo.org.uk
informingcarers carers information service @informingcarers
Part of The Whitgi Foundaon
Registered charity 312612
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SUBMIT
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