Register With Us – Hartlepool Carers

To register with us, simply complete the below form. Alternatively, you can download and return the attached form via email to staff@hartlepoolcarers.org.uk or via post to 19a Lowthian Road, Hartlepool, TS24 8BH.

If you have any queries please call 01429 283095.

Hartlepool-Carers-Registration-Form-1 Download

Name *

First

Last

Carers Address *

Postcode *

Date of Birth *

e.g 01 January 2020

Contact Telephone Number *

Email *

Council Ward *

GP Surgery *

School/College/University attending (if applicable)

Ethnicity *

Who do you care for? *

What is the primary reason you care for the person above? *

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) https://www.hartlepoolcarers.org.uk/data-protection

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 *

How did you hear about us? *

Date *

e.g. 01 January 2020

Phone