Register

To register with us as a carer please complete the form below and a member of our team will be in touch to discuss your registration in more detail. The form will also register your details for our newsletter.

First Name

Surname

Carers Address

Postcode

Date of Birth

Ethnicity

Phone Number

Email Address

GP Surgery

Educational Setting (if applicable)

Have you gained consent to make this referral on behalf of the carer/family (if applicable)

I agree to Hartlepool Carers processing the information I have provided on this form for the purposes of providing the full range of services offered by Hartlepool Carers

I agree for Hartlepool Carers to take photographs for the use of promotional and advertisement needs of the organisation. I understand that photographs may be used on social media as a means of advertising

Department/person completing referral

Name of Person Completing Form

Contact details for person completing form (if different to carer)

How did you hear about us

Why would you like to register with us?

Date

Be part of the commuity

19A Lowthian Road, Hartlepool, TS24 8BH

Mon-Thurs 9am-5pm, Friday 9am-3pm

01429 283095

staff@hartlepoolcarers.org.uk

Register

It only takes a few minutes to register

About Hartlepool Carers