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  • Carers Hub Reg Form

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    Carers' Hub Lambeth Network registration form. Please state your ethnic group: white First Name __________________________________ Black or Black British British African Irish Asian or Asian British Phone Number _____________................_____________________ Mobile do you want to receive all our mailouts? Indian White and Black African White and Black Caribbean do you have a disability or long term illness? yes No If yes, what is the nature of your disability / illness? Vietnamese Latin American Portugese Cypriot Any other __________________________ Sexual

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    Carers' Hub Lambeth Network registration form. Please state your ethnic group: white First Name __________________________________ Black or Black British British African Irish Asian or Asian British Phone Number _____________................_____________________ Mobile do you want to receive all our mailouts? Indian White and Black African White and Black Caribbean do you have a disability or long term illness? yes No If yes, what is the nature of your disability / illness? Vietnamese Latin American Portugese Cypriot Any other __________________________ Sexual

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    22 Ansichten2 Seiten

    Carers Hub Reg Form

    Hochgeladen von

    CCSouthThames
    Carers' Hub Lambeth Network registration form. Please state your ethnic group: white First Name __________________________________ Black or Black British British African Irish Asian or Asian British Phone Number _____________................_____________________ Mobile do you want to receive all our mailouts? Indian White and Black African White and Black Caribbean do you have a disability or long term illness? yes No If yes, what is the nature of your disability / illness? Vietnamese Latin American Portugese Cypriot Any other __________________________ Sexual

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Als PDF, TXT herunterladen oder online auf Scribd lesen
    Markieren Sie unangemessene Inhalte
    von 2

    Carers' Hub Lambeth Network Registration Form

    About You
    Title Mr/Mrs/Ms/Miss Please state your ethnic group:

    Surname___________________________________________ White British Irish

    First Name _________________________________________ Other _____________________________________

    Address____________________________________________ Black or Black British


    African Caribbean
    ___________________________________________________

    ___________________________________________________ Other_____________________________________

    Postcode___________________________________________ Asian or Asian British


    Email______________________________________________ Indian Pakistani Bangladeshi

    Phone Number _____________________________________ Other_____________________________________


    Mobile_____________________________________________ Mixed
    White and Black African
    Do you want to receive all our mailouts?
    White and Black Caribbean
    Do you want to receive our newsletter?
    White and Asian

    Male Female Other _________________________________________


    Are you
    Other Groups
    What is your date of birth? ___________________________ Chinese
    Middle Eastern
    Vietnamese
    Do you have a disability or long term illness? Latin American
    Yes No Portugese
    If yes, what is the nature of your disability/illness?
    Cypriot

    ___________________________________________________ Any other _________________________________

    ___________________________________________________ Sexual Orientation


    Heterosexual/Straight Gay Woman/Lesbian
    Gay Man Bisexual
    What is the name of your GP Practice?
    Other Rather Not Say

    ___________________________________________________ Religion/Faith
    Buddhist Muslim
    Christian Sikh
    Do you speak English?_______________________________
    Hindu None
    If not or not much, what language do you prefer?________ Jewish Other

    Rather Not Say


    ___________________________________________________
    Please Turn Over
    About the Person You Care For
    Please give the details of the person for whom you are the main carer. Put brief details of the other
    people who you care for in the 'Do you care for anyone else' section below.

    What is your relationship to the person you care for?

    E.G my friend/my partner/my neighbour/my parent/my child etc.

    __________________________________________________

    Male Female
    Are they

    What is their date of birth? _________________________

    Does this person live with you Yes No

    What is their main disability/illness?


    _________________________________________________

    _________________________________________________

    __________________________________________________

    How many hours of care do you give a week?


    Under 20 Hours 20 - 50 Hours 50+ Hours

    Do you get and help with caring? Yes No


    Sometimes

    If yes, from who? __________________________________

    __________________________________________________

    __________________________________________________

    Do you Care for Anyone Else? _______________________


    __________________________________________________

    Have you had a carers assesment?


    Yes No

    If yes, when?______________________________________

    Some of your information may be shared for the purposes of


    How Did You Hear About the
    monitoring our services. Please tick this box if you do not Hub?___________________________
    want any of your details to be shared. ___________________
    We may occasionally share relevant information with you.
    Please tick this box if you do not want to receive such Please Return to Carers Hub Lambeth,
    correspondance. 336 Brixton Road, London, SW9 7AA

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