Name *
Address *
Postcode *
Telephone Number *
Date of Birth *
Ethnicity *
Email Address *
Would you like to receive weekly Carers News from us by email? *
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GP Surgery *
Your GP surgery is required to hold a Carers Register. Is your surgery aware that you are a Carer? *
 Yes
 No
Do you have any health difficulties? e.g. hearing/speech problems, medical condition etc.
Name of Person You Care For *
Your Relationship to them *
What Are Their Health Issues? *
Their Date of Birth *
Which ways are you happy for us to contact you? (tick all that apply) *
 Phone
 Email
 Letter
 No Preference
How did you hear about us?
Your details will be put on our database but we do not share your information with anyone else
 I do not want to be on your database
You will receive our six monthly newsletter by email (it helps save money!) - if you would prefer to have a copy by post, please tick this box
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