Form to join the Community of Carers

SECTION 1: ABOUT YOU: These first set of questions are about you as the carer (the person offering support to a family member or friend).

Your First Name(s)

Your Surname

Your Home Address & Postcode

Your Telephone (landline & mobile)

Can we leave a message and say where we are calling from?
---YesNo

Your Email Address

Your Date of Birth (DD/MM/YYYY)

Do you have any accessibility needs or require any support to access our services

We provide a range of activities & workshops that you may sign up to attend in the future, if you have any support needs please let us know.

Your current employment status
---RetiredStudyingUnemployed and seeking employmentUnable to work due to caring commitmentsWorking Full-timeWorking Part-time

How did you hear about the Carers Centre? Please give detail where applicable eg GP surgery name

SECTION 2: EQUALITIES MONITORING. The Carers Centre is committed to equality of opportunity for everyone. By providing answers to these next questions you help us ensure that we make our services as accessible as possible. These questions are optional and your answers will be used for equal opportunities monitoring purposes only.

Your Gender

Your Sexual orientation

Your ethnicity
---White - English/Welsh/Scottish/British/Northern IrishWhite - IrishWhite - Gypsy/Irish TravellerWhite - RomaWhite - Other White BackgroundAsian or Asian British-IndianAsian or Asian British - Other Asian BackgroundOther Ethnic Group - YemeniOther Ethnic Group - OtherMixed - White And Black CaribbeanMixed/multiple Heritage - White and Black CaribbeanMixed/multiple Heritage - White and Black AfricanMixed/multiple Heritage - White and AsianMixed/multiple Heritage - Other Mixed BackgroundBlack/African/Caribbean or Black British - AfricanBlack/African/Caribbean or Black British - CaribbeanBlack/African/Caribbean or Black British - SomaliBlack/African/Caribbean or Black British - Other Black

Do you consider yourself to be disabled?
---YesNo

SECTION 3: ABOUT YOUR CARING ROLE: These questions are about your caring role and the person(s) that you look after who has care and support needs. It’s important we know a little about the person(s) you help so we can understand how best to support you in your role caring for them.

How long have you been caring in your current caring role
---12 months or lessMore than 1 yearUnknown

What is your relationship to the cared-for person? You are:
---Caring for a spouse or partnerCaring for a parentCaring for your adult childCaring for your child under 18 years oldCaring for any other relativeCaring for a friend or neighbour

Cared-for person's First Name

Cared-for person's Surname

What is the cared-for person's primary (main) condition or disability that you support them with?
---Physical DisabilityCancerVisual ImpairmentHearing ImpairmentDual Sensory ImpairmentMental Health ConditionLearning DisabilityAutism or Aspergers SyndromeDementia or Memory & Cognition ConditionsFrailtySubstance Misuse or AddictionOther

Cared-for person's date of birth (DD/MM/YYYY)

Are they receiving support from Adult Social Care?
---YesNoUnsure

If you are a carer for more than one person please complete and send this form - then complete another form for the second person. If you are a carer for more than two people please call us on 0114 278 8942.

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