Campaign Referral Form

Referral Form

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

Carer Details & Contact Information

Referral Date*

Date consent obtained

Title*

Forename(s)*

Preferred Known As

Surname*

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

Address line 2

Address line 3

Address (Village/Town/City)*

Postcode*

Telephone Number*

Is it OK to leave a message?*

Email Address

Date of Birth*

Consent & Support Information

We send out a quarterly magazine and occasionally other carer related information. We will not share your information with other organisations for marketing purposes

I would like to receive carer related communications from Devon Carers – such as the quarterly magazine*

Please note that if you would like to be referred to Citizens Advice for a discussion about benefits and how to maximise your income, we will need to contact you for additional information.

I would like to be contacted by Citizens Advice to discuss what benefits I am entitled to and how I can maximise my income*

Yes

I confirm that Devon Carers can hold my information in order to provide me with carer services. If referring on behalf of the carer, I confirm that the carer named above has agreed to this referral*

Yes

Would you like us to contact you?*

Yes

Reason you'd like us to contact you

Referral Information

Please provide your contact details if you are completing this referral on behalf of someone else in case we need to contact you to confirm any of the information provided.

Referrers name

Referrers telephone number

Referrers relationship to carer*