Registration form

Please use this form if you or the person you are referring is an unpaid adult carer who cares for someone who is an adult and lives in the Devon County Council area.

Any fields marked with an asterisk * are mandatory. You will not be able to submit your registration unless these fields are completed.

Consent information

By completing this registration, the person named below has agreed to Devon Carers holding their information for the purpose of supporting them in their caring role and that they provide unpaid care to a family member or friend who is ill, frail, disabled, has a mental health issue or substance misuse problem. Information is shared with Devon County Council and the NHS as the service commissioners, to provide the best possible support.

I confirm that I am an adult (18+) and care for:*

The council area where the person I care for lives is:*

Registration information

Registration Date*

Date consent obtained

Who is Registering?*

Reason for registration*

All newly registered carers will receive a carer information pack. If you would like us to contact you as part of your registration, please select yes below and we will phone you. If not select ‘no’.

Yes

Carer Details & Contact Information

Title*

Forename(s)*

Preferred Known As

Surname*

Date of Birth*

Address line 1 (Flat/House Number & Street)*

Address line 2

Address line 3

Address (Village/Town/City)*

Postcode*

What is your preferred method of contact?

Do you have any communication needs such as a hearing or speech problem? Do you require additional support, i.e. enabler, translator, advocate etc.? Please specify

Email Address

Landline Telephone Number

Is it OK to leave a message? (Without consent we are unable to leave messages)

Mobile Telephone Number

Is it OK to leave a message on your mobile?

Yes

Your GP Surgery

Please select your GP Practice from the list below. If you can’t find your surgery use the ‘GP Surgery – Unknown’ option. If you live out of the Devon County Council area and your GP Practice is not on the list, please select ‘GP Surgery – Out of County’

GP Surgery

Devon Carers Magazine

Would you like to receive our quarterly magazine You Care, We Care?

Please specify the alternative version required

The person I care for

How many adults do you care for?

The conditions listed below are definitions taken from the Office for National Statistics website. Please select the option that most accurately describes the main condition of the person you primarily care for.
Key:
MH = Mental Health
Dev = Development
Neu = Neurological
Phy = Physical
Sen = Sensory

Main condition of the person you primarily care for

Equality & Diversity Monitoring

These questions will help us check that we have reached a representative section of society and help us to identify inequalities. Those who are in the minority groups may experience isolation, ‘invisibility’ and exclusion and this is particularly true of carers. It is therefore important we take notice of their experience and needs.

You do not have to provide this information, or you may choose to provide only some. Any information you do provide will help us to plan services for all carers.

Gender Identity

Ethnicity

The ethnicities listed below are taken from the Office for National Statistics website. Please select the option that most accurately describes your ethnic group.

Religious Group

The religions listed below are taken from the Office for National Statistics website. Please select the option that most accurately describes your beliefs.

Sexual Orientation

The list below is taken from the Office for National Statistics website. Please select the option that most accurately describes your sexual orientation.

Thank you for registering with Devon Carers. If you requested that we contact you to discuss support, we will be in touch soon.
If you feel your referral is urgent, please refer to our contacts page https://devoncarers.org.uk/contact/ for more information on how to get in touch.