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Overview
Join The Carers Information Service
About You
Title
(required)
First name
(required)
Last name
(required)
Date of birth
(required)
Gender
(required)
Address
(required)
Town
(required)
Postcode
(required)
Daytime phone number
(required)
Mobile phone number
Email (please provide your email address if you are happy to receive information by email)
Education and employment
(required)
Please select...
If you selected "Other" please describe here
Ethnicity
(required)
Please select...
If you selected "Other" please describe here
Does your GP surgery know you are a carer?
Some GP surgeries offer priority appointments andother carers support
Are you on the carers register at your GP surgery
(required)
Please select...
No
Yes
Don't know
If no / don't know, would you be happy for us to let your GP surgery know that you are a carer?
Please select...
No
Yes
About The Person You Support
Please tell us about the person you support. If you support two people, please give us the second person's details on the next page. If you support more than two people, please complete the form only for the two people that need the most care.
Date of birth
(required)
What is your relationship to the person you support (for example are you their husband, daughter, neighbour)
(required)
Please tell us which town the person you support lives in
(required)
Please select...
Bournemouth
Christchurch
Poole
Does the person you support live with you?
(required)
Please select...
Yes
No
Please describe the needs of the person you support (tick all that apply)
(required)
Other (please describe in box below)
Other
Ethnicity of the person you support
(required)
Please select...
Other
Do you support another person?
(required)
Please select...
Yes
No
Other Information
How did you find out about the Carers Information Service?
Please select...
If you selected 'other' or want to tell us more about how you found out about the Carers Information Service, please tell us here
Any personal information you provide us with, will be held and used in accordance with the Data Protection Act 2018. If you would like to find out more information about how we will use your information, please see our Privacy Notice here: crispweb.org/privacy-notice.aspx
(required)
Please select...
I agree
