Register With Us – Hartlepool Carers

Name *

First

Last

Carers Address *

Postcode *

Date of Birth *

e.g 01 January 2020

Contact Telephone Number *

Email *

Council Ward *

GP Practice Details *

School/College/University attending (if applicable)

Ethnicity i.e. White British *

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. *

Hartlepool Carers need your permission to hold and process the data supplied on this form. Be assured, we will have regard to prevailing data protection principles and we have a Data Protection Policy and a Data Protection and Freedom of Information Processing Procedure, which we encourage you to review on our website. Please tick "Yes" or "No" to all of the following statements (N.B. "No" may mean we cannot support you)

I agree to Hartlepool Carers using relevant information I have provided in this form to allow them to work with other organisations to support the care/support programes provided. *

I agree to Hartlepool Carers securely storing relevant information I have provided. *

I agree to Hartlepool Carers supplying funders of the service (e.g. Councils, Charity Foundations) your anonymized data which demonstrates the effectiveness of this service and allows them to monitor our adherence to contractual obligations. *

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. *

Referred by *

Carers Signature *

How did you hear about us? *

Date *

e.g. 01 January 2020