Register with Wandsworth Carers centre Step 1 of 3 33% Carer Registration FormThank you for your interest in Wandsworth Carers’ Centre and Carers Partnership Wandsworth. We provide information and support to all unpaid Carers over the age of 16yrs who either live in the borough of Wandsworth, have a GP in Wandsworth or care for someone who lives in the borough of Wandsworth. To enable you to use the services of the partnership, we require you to register with us. Information about the CarerAre you actually the carer completing this registration?*YesNoPlease tick to confirm you have permission / consent from the Carer to complete this registration on their behalf*I have permissionIf you are registering on behalf of someone else, what is your connection / relationship with the Carer you are registering on behalf of?*What is your name?* First Last What is your phone number?*What is your email address? Name of carer* TitleMrMrsMissMsOther Prefix First Last Date of birth of carer* DD MM YYYY Address of carer* Street Address Address Line 2 City Postal Code Email Address of carer Contact Number of carer – Main*Mobile Number of carerEmergency Contact Name for carer First Last Emergency Contact Number for carerRelationship of carer to emergency contactGP Name and Surgery*How/where did you hear about us?*Is there anyone under 18 yrs old living with the person cared for?*YesNoAre they a young Carer?YesNoSupport is available for young Carers. Contact Wandsworth Council for more information. Information about the person cared forName* MrMrsMissMsOther Title First Last Date of birth* DD MM YYYY Address (If different to carer's) Street Address Address Line 2 City Postal Code Relationship to Carer*GP Name and Surgery of cared for person*Health Condition and Support needs?* Autistic spectrum disorder Dementia Learning disability Mental Health Multiple Disabilities Older Person Physical disability Physical illness Substance misuse Other Other conditionsWhat type of care does the carer provide? Personal Care. i.e. washing and dressing Practical: i.e. assisting with medication, cooking, shopping, advocacy Emotional: i.e. listening and reassuring Which of our services would you like to access?Please check all the services you would like to accessServices* Newsletter Training and Workshops Counselling Information and Advice Respite One to One Support and Advocacy Peer Support i.e. Groups, activities and trips Back Care and Therapies Benefits Advice Other Other supportIf you choose Newsletter – Email or post?EmailPostPrivacy StatementPlease tick to confirm you have read and understood Wandsworth Carers’ Centre’s privacy statement (link above) and give permission for my information to be stored on Wandsworth Carers’ Centre’s database. I also give permission for Wandsworth Carers’ Centre to contact me by phone, email, post. Yes Please note, you can opt out of text or emails at any time by contacting Wandsworth Carers’ Centre or by responding to any text or email you receive from us.