Privacy Policy
I agree to Carer Support Wiltshire on behalf of Carer Support Dorset holding my personal information in accordance with their Privacy Policy
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Please select an option...
Yes
No
Third Party
Where did you hear about Carer Support Dorset?
Referrer Information
Referrers Name/Organisation Referring
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Contact Number
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I have received consent to refer this Carer to Carer Support Dorset
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Yes
No
Reason for Referral
Reason for Referral
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To be registered and receive information and advice, including the Carers Discount Card
To be registered and receive a phone call to discuss my caring role and receive information and advice, including the Carers Discount Card
Contact Preference
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Email
Telephone
Carer general details:
Surname
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Forename
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Title
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Address line 1
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Address line 2
Address line 3
Town
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County
Postcode
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Main telephone number
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Mobile Number
Email address
Carer personal details:
Gender
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Please select an option...
Male
Female
Non Binary/Transgender
Prefer Not To Disclose
Date of Birth
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Ethnic Group
Please select an option...
Asian Or Asian British - Bangladeshi
Asian Or Asian British - Chinese
Asian Or Asian British - Indian
Asian Or Asian British - Japanese
Asian Or Asian British - Pakistani
Black Or Black British - African
Black Or Black British - Caribbean
Black Or Black British - Other Black Background
Did Not Wish To Disclose Ethnic Group
Mixed - Other Mixed Background
Mixed - White And Asian
Mixed - White And Black African
Mixed - White And Black Caribbean
Not Stated
Other Ethnic Group
White - British
White - European
White - Gypsy Or Irish Traveller
White - Irish
White - Other White Background
Employment status
Please select an option...
Retired
Not Working Due To Caring
Not Working Due To Illness
Full-Time
Part-Time
Student
Unemployed
Volunteering
Did Not Disclose
Details of the person you care for
Do you care for someone under the age of 18
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Yes
No
Please provide details of the person you care for
Surname
Forename
Relationship to you
Main Disability
Do you care for more than one person?
Yes
No
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