Privacy Policy

I agree to Carer Support Wiltshire on behalf of Carer Support Dorset holding my personal information in accordance with their Privacy Policy *

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 *

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 *

Surname *

Forename *

Title *

Address line 1 *

Address line 2

Address line 3

Town *

County

Postcode *

Main telephone number *

Mobile Number

Email address

Gender *

Date of Birth *

Ethnic Group

Employment status

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