Registration Form

First Name*

Last Name*

Date of Birth*

Please note that if you are under 16, an adult (parent, guardian or professional) will need to register you with our young carers services at the Junction (thejunctionfoundation.com).

Age of cared for person*

—Please choose an option—UnknownUnder 66 to 1011 to 1516 to 1819 to 2425 to 3435 to 4445 to 5455 to 6465 to 7475 to 8485 to 9495 to 104105+

Address*

Telephone

Email Address

Carers Together email regular newsletters and information for carers

Information

Please tick if you would not like to receive the following:
Newsletter by emailNewsletter by PostInformation for Carers

You can choose how we keep in touch with you.

Phone can be particularly helpful as it enables us to follow up your registration with a call.
Please confirm if we may contact you in the following ways:

Telephone / Mobile*

Please confirm whether or not we can contact you by phone.

YesNo

Text*

Please confirm whether or not we can contact you by text message.

YesNo

Email*

Please confirm whether or not we can contact you by email.

YesNo

Post*

Please confirm whether or not we can contact you by post.

YesNo

What is your preferred method of contact*

Telephone / MobileTextEmailPost

Ethnicity*

This is to allows us to monitor our inclusivity.

—Please choose an option—White BritishWhite Gypsy/RomanyWhite Traveller of Irish heritageAny other White backgroundChineseAsian or Asian British BangladeshiAsian or Asian British IndianAsian or Asian British PakistaniAny other Asian backgroundBlack or Black British AfricanBlack or Black British CaribbeanAny other Black backgroundMixed White and AsianMixed White and Black AfricanMixed White and Black CaribbeanAny other ethnic groupAny other mixed backgroundPrefer not to say/Not known

Gender*

MaleFemaleOther

If Other please State

Employment Status*

—Please choose an option—Employed (Full Time)Employed (Part Time)Long-term sick or disabledHomemakerUnemployedSelf EmployedRetiredOther

Name of GP Surgery / Practice

Do you have any specific communication needs, e.g. language, large print, audio, translation?*

YesNo
If Yes please state:

About who you care for

Optional – you don’t have to complete this section, but it will help us understand how best to support you.

Who do you care for?

—Please choose an option—BrotherCarerDaughterFatherFriendGrandchildGrandparentHusbandMotherNeighbourPartnerSisterSonWifeOther

Condition of main cared for person

Please give a brief description of the condition for the main person you care for.

Do you Care for anyone else?

—Please choose an option—BrotherCarerDaughterFatherFriendGrandchildGrandparentHusbandMotherNeighbourPartnerSisterSonWifeOther

Are there any other agencies supporting you in your caring role, such as Social Care, etc.?

—Please choose an option—YesNo

If Yes Please give details:

Do you require immediate information and support from Carers Together, if Yes please give details.

—Please choose an option—YesNo
if Yes please give details

How did you hear about Carers Together?

—Please choose an option—Health ProfessionalOther ProfessionalSocial Care ProfessionalPosterWord of MouthWebsiteLeaflet - D CafeLeaflet - DASLeaflet - GeneralMagazineFacebookTwitterEvent - Info dayCarers Together StaffAlready Registered

Carers Voices Membership

We offer opportunities to take part in consultations and campaigns to help improve local services for other carers.

if you are not interested in joining Carers Voices please tick this box

Preferences

You can change your preferences at any time – by emailing info@carerstogether-rc.org.uk, phoning 01642 488977 or by writing to Carers Together, Innovation Centre, Vienna Court, Corfu Way, Kirkleatham Business Park, Redcar TS10 5SH.

By clicking on the submit button I am confirming that I am the named carer and agree to the processing of my data and I have read the Carers Together Privacy Policy.