1st (MAIN) SHARED LIVES CARER
Title (Mr, Mrs, etc) / Forename
Surname
2nd (JOINT) SHARED LIVES CARER
Title (Mr, Mrs, etc) / Forename
Surname
Address: / Postcode:
Tel No: / Mobile No:
Email:
MEMBERSHIP PACKAGES - Please mark the appropriate package
FULL MEMBERSHIP
including Public Liability cover / BASIC MEMBERSHIP
without Public Liability cover
£89 for single carers / £51 for single carers
£99 for joint carers / £66 for joint carers
  • Please register me/us as a Shared Lives carer Member of Shared Lives Plus entitling me/us to the special Shared Lives Carers’ legal expenses insurance cover.
  • I am happy for my details to be passed to the Shared Lives Carer contact in my local area.
  • I accept that information held by Shared Lives Plus will be kept in accordance with the Data Protection Act (1998) and that I have the right to access those files following the procedure described in the Shared Lives Plus Data Protection Policy, a copy of which is available from Shared Lives Plus on request.
  • I am committed to following the Shared Lives Plusmembers’ Principles of Partnership which I have read and understood.

I/we enclose cheque/postal order for £………………… made payable to ‘Shared Lives Plus’ - Please write your name, address and post-code on back.

You can forward your membership form to our office and we will call you to pay by card

Signed
(1st carer) / Dated
Signed
(2nd carer) / Dated

Shared Lives Plus members use their homes in a special and unique way, so you should ensure your current household insurance provides the correct level of cover. Towergate Insurance have a bespoke household policy wording for Shared Lives Plus members. If you tick this box, we will ask Towergateto contact you to discuss a quotation or you can call them on 0113 384 4000. We will not share your contact details with anyone else.

Details of the Shared Lives Scheme I/We are registered with:
Name of Worker
Name of Scheme
Scheme Address: / Postcode:
Tel No:
Email:

I confirm that:

The named Carer(s) is/are approved by my Shared Lives Scheme which meets the regulatory requirements set by my government and adheres to the Shared Lives Plus Good Practice Standards

Signed / Dated

Have you remembered?
A useful checklist

  • Have you given us all your contact details?
  • Have you told us which membership package you want? Full/Basic
  • Has your scheme countersigned the application?
  • Have you attached the correct payment?