Young Carer's Registration Form

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Are you providing unpaid care and support to a family member or friend who is ill, frail, disabled or has mental health or substance misuse problems? If you are then you are a carer and we would like to support you. Please fill in this form

Personal Details

Sex:

Can we contact you by email?: *

Please double check you've entered the correct email address

How many hours per week are you caring?: *

Is the school/college aware that you are a carer?:

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Who Are You Caring For?

Would you like to receive more information and support from the carers lead at the practice?: *

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Your Consent

I am a young carer and I consent for my details to be held by my surgery and for them to contact me about the patient named below: *

I am a young carer and would like my caring role to be recorded on the Practice Carer's Register: *

Parental Consent

I am the Parent/Guardian of the carer named above and I consent for their details to be held by the surgery and for their caring role to be recorded on the practice carer's register: *

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Consent Of The Person You Care For

I give consent for my carer named above to speak to the practice on my behalf : *

I consent to them having access to my full medical records: *

I consent to them only having access to make appointments : *

Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Bridgeside Surgery

Young Carer's Registration Form

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