Information about you (the carer)

By submitting this form, I confirm that I am an unpaid carer in East Sussex and I wish to receive details of how I can book an appointment for a COVID-19 vaccination. I give my consent for Care for the Carers to hold my personal data on their secure database in line with their privacy policy (https://www.cftc.org.uk/privacy-policy/), and for Care for the Carers to contact me with details of how to book an appointment for a COVID-19 vaccination or to share my data to enable me to access the vaccination. If you are unable to complete this form, please call Care for the Carers on 01323 738390.

Title*

Surname*

Forename(s)*

Address line 1*

Address line 2

Address line 3

Address line 4 (Town)*

Address line 5 (County)*

Postcode*

Main Telephone No.*

Email Address (Main)*

Date of Birth*

Gender*

Ethnic Group*

Sexual Orientation*

Marital Status*

Religious Group*

GP Surgery*

What is the relationship of the person you care for to you?*

What is the main health condition of the person being cared for?*

Carer’s main health issue or disability, if any (if none, select no disability or health issue)*

Would you like to receive our monthly e-newsletter?*

Would you like to receive our quarterly CareLine magazine by email?*

Please comment in the box below if you would like support from Care for the Carers in relation to your caring role. We will endeavour to contact you as soon as possible, although there may be a delay whilst we respond to the high volume of enquiries. If you need support urgently, please contact us on 01323 738390 or info@cftc.org.uk

Referral Project

Thank you for registering with Care for the Carers. We will email you with details of how to access your vaccination as soon as the national booking process is available. We are expecting high levels of interest so please bear with us if you don’t hear back straight away. Please monitor your junk folder in case our email gets diverted there.