Privacy Policy
I agree to Carer Support Wiltshire on behalf of Carer Support Dorset holding my personal information in accordance with their Privacy Policy
Please select an option
Yes
No
Third Party
Where did you hear about Carer Support Dorset?
Referrer Information
Referrers Name/Organisation Referring
Contact Number
I have received consent to refer this Carer to Carer Support Dorset
Please select an option
Yes
No
Reason for Referral
Reason for Referral
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
Brief outline of Caring role
Contact Preference
Please select an option
Email
Telephone
Carer general details:
Surname
Forename
Title
Address line 1
Address line 2
Address line 3
Town
County
Postcode
Main telephone number
Mobile Number
Email address
Carer personal details:
Gender
Please select an option
Male
Female
Non Binary/Transgender
Prefer Not To Disclose
Date of Birth
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
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
Submit