Carers Hub registration form

By completing and submitting the form below you are registering to be on our carer hub mailing list. We will then be able to post/email updates on carer support available at our carer hubs.

Title*

First name*

Last name

Address*

Postcode*

Telephone number*

Mobile number

Email address

Connection to Trust (tick as many as applicable)*

Carer
Staff Carer

Which service(s) are you connected to/do you have experience of?

Would you require any assistance in evacuating a building should there be an emergency, i.e. assistant to walk, get up or down steps etc*

Yes
No

We ask this in order that we can make provisions for your safety

How did you hear about the Carers Hub?

We will not pass on any of your details to anyone else, and we will keep all the information about you in accordance with The Data Protection Act 1998.

Print name*

To be completed by parent, guardian or carer as appropriate if person completing form is under 16 years of age. Name:

Date

Are you interested in involvement opportunities?

Yes
No

To help insure the people involved represent the diverse communities of Bradford, Airedale and Craven, it would help us if you indicate the following information. The information is for monitoring purposes only and will remain confidential.

Gender

Female
Male
Transgender
I do not wish to disclouse

Ethnic group

If you selected 'any other Ethnic group' please specify

Faith/Religion

If you selected 'other' please specify

Do you speak English?

Yes
No

If no or not much, which language to you prefer?

Do you consider yourself to have a disability or limiting long term illness?

Yes
No
I do not wish to disclose