Test

Apply for Carers Card

Form for a carer to apply for a Carers Card.

The person I care for lives in South Gloucestershire.*
- Yes
- No
If the person you care for lives in Bristol, please apply for a card on the Bristol City Council website
Hidden
Beginning of form
Your full name*
Title First Last
Gender*
- Male
- Female
- Prefer not to say
Date of birth*

Day
Month
Year
Your address*
Street Address Address Line 2 City County Post Code
Home phone
Mobile Phone
Work Phone
Your email address*
GP surgery name*
I am happy for my GP to be informed that I am a carer*
- Yes
- No
I understand that the data I provide will only be used by the provider(s) responsible for maintaining Connecting Carers as per their Privacy Policy
Agreement*

Yes
Disability and Communication Needs*
Please tell us about any disability, communication or language needs you have and how this affects you? If you are affected by any of these please give details in the box below
An interpreter can be arranged to help people who require assistance in written or spoken communications
Please describe your needs
The person I care for has these difficulties/disabilities
Please tick all that apply
Physical disability
Learning Difficulty
Substance misuse
Hearing loss
Elderly frail
Sight loss
Long term illness
Mental Health
Dementia
Other
Other
Please specify
What main illness/condition does the person you care for have?
Please answer the following optional questions about yourself
The information you supply will help us to better understand the needs of all carers so that we can tailor our support to you. We will also use this information to monitor the services we provide. Responses to these questions will remain confidential. Individuals will not be identified and personal details will not be published.
What is your ethnicity
Other ethnicity
What is your religion/belief?
Other religion
What is your sexual orientation?
Other sexual orientation
Do you identify as a transgender person?

Yes

No

Prefer not to say
On average, how many hours a week do you help the person you care for?

Less than 50 hours

More than 50 hours
Details of the person you care for
Name*
Title First Last
Gender*

Male

Female

Prefer not to say
Date of birth*

Day
Month
Year
Address*
Street Address Address Line 2 City County Post code
Home Phone
Mobile Phone
Other daytime Phone
GP surgery name*
The person I care for is my*
e.g. wife, son, partner, friend, neighbour
Disability & Communication needs
Please tick anything they have difficulty with & provide brief details where necessary
Communication
Memory difficulties
Aggressive/Challenging behaviour
Eating/Drinking
Food preparation
Moving around
Washing or dressing
Toileting
Allergies
If you have ticked any of the boxes above please give details in the box below
Is there anything else they may need essential assistance with if you or your contacts were not there to support them?
Emergency Contact Details
A contact is a person (not the carer themselves) who can be called in an emergency. The emergency contact is the person who will be contacted first. If you do not have any emergency contacts, you can still register for a Carers Emergency Card. Read more HERE.
Keysafe*

Yes

No
Keysafe location at property
After submitting your form, phone: 0117 958 9907 at Carers Support Centre, leaving your name and keysafe number only.
Emergency contact 1
Name*
Prefix First Last
Address*
Street Address Address Line 2 City County Post code
Home Phone
Mobile Phone
Work Phone
Relationship to the cared for person*
e.g. wife, son, friend, neighbour
Also a keyholder?

Yes

No
Emergency contact 2
Name
Prefix First Last
Address
Street Address Address Line 2 City County Post code
Home Phone
Mobile Phone
Work Phone
Relationship to the cared for person*
e.g. wife, son, friend, neighbour
Also a keyholder?

Yes

No
Keyholder 1
Name
Prefix First Last
Address
Street Address Address Line 2 City County Post code
Home Phone
Mobile Phone
Work Phone
Keyholder 2
Name
Prefix First Last
Address
Street Address Address Line 2 City County Post code
Home Phone
Mobile Phone
Work Phone
Additional Information for the Rapid Response team
If a member of the Rapid Response Team is called to the property what do they need to know? E.g. information about access to the property not previously mentioned i.e. steps, gates, pets etc.
Information
Is there a Message in a Bottle at the property?
It is very important to let the Emergency Call Centre know if any information including keysafe numbers change. You can do this by calling the number on the card.

Yes

No
Your consent
In the event of an emergency, I agree that the information on this form can be shared with anyone named on it, or with professionals and agencies that may need to be involved in providing emergency care.
I give consent*

Yes
Please tell us where you heard about the Carers Emergency Card*
GP surgery
Hospital
South Gloucestershire Council
Carers Support Centre
Other
Please specify
Consent*
See our Privacy page Privacy.
By using this form you agree with the storage and handling of your data by this website.
Phone
This field is for validation purposes and should be left unchanged.

28503

Apply for Carers Card

Beginning of form

Latest News

Read our Impact Report for 2023/4

The transformation of our Young Carers garden

Carers Support Centre celebrates after receiving National Lottery funding for Walk and Talk for carers

Bristol carer on BBC during Carers Week

Join our supporter list

Carers Support Centre

Beginning of form

Share this:

Latest News

Read our Impact Report for 2023/4

Share this:

The transformation of our Young Carers garden

Share this:

Carers Support Centre celebrates after receiving National Lottery funding for Walk and Talk for carers

Share this:

Bristol carer on BBC during Carers Week

Share this:

Join our supporter list

Carers Support Centre