Wired, Oldham Carers Centre.

Carers Registration Form

Carers Information
First Name: / Surname:
DOB: / Gender:
Address:
Postcode: / Telephone:
Ethnic origin: / Mobile:
Faith: / Preferred Language:
Email Address:
Name and Address of your GP: We can let your GP know that you are a Carer
GP Practice: / GP Name:
Address:
Postcode: / Telephone No:
What is the relationship to the person you care for?
Mother: / Father: / Spouse: / Daughter:
Son: / Brother: / Sister: / G. Parent:
Neighbour: / Friend: / Other Family Member:
Other:
Approximate number of hours per week spent caring? / □ 0-5 □ 6-10 □ 11-20 □ 21-50 □ 50+
Do you carry out paid work? / No: / Full Time: / Part Time: / Retired:
Do you have an illness or disability?
(if yes please state what) / Yes No
Does the person you care for pay their Council Tax to Oldham Borough Council
(This information allows us to identify the services that the Carer can access if the person they care for is an Oldham resident) / Yes / No
Which of the following would best describe the illness of the person you care for?
Mental Health: / Alzheimer/Dementia: / Physical/Sensory:
Learning Disability: / Substance/Alcohol Misuse: / Frailty due to age:
Child with Disabilities: / Other: (Please state)
Would you like to talk to one of our team about your caring role?
Yes: / No:
Would you like to apply for a Carers Assessment?
Yes: / No:
How would you like to receive our quarterly carers magazine?
Email: / Post: / Collect / None:
Please tell us how you came by our registration form:

Why this information is important

  • The information requested will help develop a register of unpaid carers within Oldham.
  • The aim is to enhance support for people who have caring responsibilities and to ensure information and support is directed to you.
  • The register may be used as a consultation tool with which to consult carers when services are being planned
  • Occasionally information held on the database will be used to produce local and national statistics on carers: No personal details will be disclosed.
  • This information may be used to inform your GP that you are a carer.
  • Statistical Information about you will only be shared with the Oldham and Oldham CCG for planning purposes.

Wired are working in partnership with Oldham Council and Oldham Clinical Commissioning Group

All Personal information provided will be processed in accordance the Data Protection Act 1998.

Should your details change or if you no longer wish to remain on the register, please inform us by

Calling 0161 770 1188 Ex1.

Carers Signature………………………………… Date………………………………………….

Once complete please post to:

Wired

Oldham Carers Centre

The Link Centre

140 Union Street

Oldham OL1 1DZ

Register byringing 0161 770 1188 Ex 1

Email:

Registered Charity, Charity No. 1060105. Registered Address: Unit 7, WirralBusinessPark. Arrowe Brook RoadUpton, Wirral, CH49 1SX

OFFICE USE ONLY: Date Registered______