IN CASE OF EMERGENCY (ICE)

Carer’s Card Application Form

The (ICE) Carer’s Card offers you and the person you care for peace of mind knowing that a plan could be activated in an emergency.

Complete and return this form to create your emergency plan. The plan holds information about the person that you care for along with details of who you would like to be contacted to care for them in the case of an emergency. It will be stored confidentially at Carers Together and Beyond Housing.

If your card is activated, the pre-planned emergency actions you have provided will be followed.

Carer‘s Together (ICE) Carer’s Card Application Form

Section1 - Cared for Person’s Details

Title

First Name *

Last Name *

Date of Birth

E-Mail *

Marital Status

Address:

Mobile Number

Home Telephone Number

Work Telephone Number

Registered with KeySafe?

Registered with Telecare?

Medical Condition

Medication?

If yes, where is it kept?

Allergies?

If yes, please provide details

In the event of an emergency, should we notify the cared for person?

How long can the cared for person be left on their own?

GP (of cared for person)

GP’s Telephone Number

GP’s Address

Section 2 - Carer’s Details

Title

First Name *

Last Name *

Date of Birth

Relationship to cared for person

Address

Home Telephone Number

Mobile Telephone Number

Work Telephone Number

GP’s Telephone Number

GP’s Address

Section 3 - Emergency Contact Details

Please ensure you have discussed this scheme with your emergency contacts and have their agreement to be contacted in an emergency.

1st Emergency Contact

Title

First Name

Last Name

Keyholder for cared person?

Relationship to carer

Address

Home Telephone Number

Mobile Telephone Number

Work Telephone Number

2nd Emergency Contact

Title

First Name

Last Name

Keyholder for cared person?

Relationship to carer

Address

Home Telephone Number

Mobile Telephone Number

Work Telephone Number

3rd Emergency Contact

Title

First Name

Last Name

Keyholder for cared person?

Relationship to carer

Address

Home Telephone Number

Mobile Telephone Number

Work Telephone Number

Section 4 - Declaration

Please tick the box below if you agree with the following statement

I agree that the contacts named can be telephoned in an emergency and that it is my responsibility to ensure that the Emergency Contacts are made aware of medical details. I agree with this information being shared with relevant agencies and also with other statutory agencies, ie Social Services, Health or Police, if it enables appropriate action to be taken for the person I care for.

Yes, I agree to the statement above *

We’ll look after your information very carefully. Our Privacy Policy explains why Carers Together collects your personal data, how we use it, who we may share it with, and sets out your rights in relation to your data. You can find our Privacy Policy here and you should read the Policy before you complete this form.

IN CASE OF EMERGENCY (ICE)

Carer’s Card Application Form

Carer‘s Together (ICE) Carer’s Card Application Form

Section1 - Cared for Person’s Details

Section 2 - Carer’s Details

Section 3 - Emergency Contact Details

1st Emergency Contact

2nd Emergency Contact

3rd Emergency Contact

Section 4 - Declaration

01642 488977

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