Register a young carer as a parent, professional or young person

Is this application being completed by:*

Parent/Guardian, other Family Member
Young Carer aged 14 or above
Agency/Professional
School

Privacy Policy and Data Protection*

I confirm as the Parent/Guardian/Other Family Member or Young Carer that I have read the Privacy Policy statement and agree with it.
I confirm as an Agency/School Professional that I have explained the Privacy Policy to the Parent/Guardian/Other Family Member.

Our Privacy Policy explains why Action for Carers (Surrey) collects your personal data, how we use it, who we may share it with, and sets out your rights in relation to your data. We recommend you read the Privacy Policy (see above link) before completing this form. If you have any questions about this form, or about how we use your personal data, please contact us on 0303 040 1234, asking for the Data Protection Officer or email [email protected]

YOUNG CARERS DETAILS:

Young Carer Name*

First Last

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Date of Birth*

DD

MM

YYYY

Please note that the child must be in school year 1 or above. If the young carer is under 5 years old, we will not be able to register them to our service. If the young person is 17 and a half (or older), please use the standard adult form.

Young Carer Phone Number*

Use your mobile or home number, whichever is best for you. Alternatively please supply a parent or guardian contact number.

Young Carer Email Address:

Do you consent to us sharing this application information with professionals/school/college?*

Yes
No
Not Applicable

Sex/Gender*

Ethnicity (Optional)

GP Surgery Name*

How many people live in the household?

PARENT/GUARDIAN DETAILS:

Parent/Guardian Name*

First Last

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Parent/Guardian Phone Number:*

Parent/Guardian Email Address:*

Preferred Time to Contact*

Is there another Parent/Guardian that lives at a different address from the young carer?

Yes
No

REFERRER DETAILS:

School/Health/Care Professional referring please complete section below

Referrer Name

First Last

Organisation (if applicable)

Referrer Phone Number

Referrer Email Address:

SCHOOL/COLLEGE:

School or College Attended*

Enter Home School or Apprenticeship if applicable

Are the School/College aware of the referral?

Yes
No

School/College Contact Name and Job Title

Full Name Job Title

School/College Contact Email address:

School or college phone number

ADDITIONAL NEEDS OF THE YOUNG CARER:

Education, Health and Care Plan

Yes
No
Not Sure

Behaviour/Emotional/Disability - Please give details:

Is this Diagnosed?

Yes
No

Medical Needs e.g. Allergies/Epilepsy:

Additional Comments

Is the young carer supported by a Child Protection Plan, Child In Need Plan or Team Around The Family?

Yes
No

About who you care for:

Optional – Completing this section helps us understand how best to support you.

Age of Main Cared for Person

Please pick the age range of the person the young carer helps

Condition of Main Cared for Person

Please pick the disability or condition of the person cares for from the list.

Does the young carer also care for another person?

Yes
No

Age of the second person the young carer is caring for

Please pick the age range of the second person cared for

Condition of the second person cared for

Please pick the disability or condition of the second person you care for from the list.

If YES, please given details of social worker or lead professional:

Name

First Last

Email

Please list any known voluntary or statutory service involvement with the family:

Please select your views of the caring role/ situation:*

Please select all that apply

Nature of caring role*

Physical - Cleaning, cooking, collecting medication, carrying things
Practical - Washing, medications, dressing
Emotional - Listening, comforting
Parenting Siblings - Helping siblings get dressed, making them dinner, helping with homework

Please select all that apply:

Please provide any other relevant information that may help us to support the young carer: how would they benefit from our support, what do they need?

Agency or School to complete this section:

Please complete the boxes below:

Referrer Name*

First Last

Referrer Email*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date*

Consent*

I confirm that I have explained the statement at the top of this form to the parent/legal guardian and that I have gained their consents as stated, and for Action for Carers Surrey to process and store the information contained on this form.

Parent/Legal Guardian to complete this consent section:

Please confirm if we may contact you by the following methods: (please tick to confirm)*

Email
Post
Phone
Text

PLEASE NOTE THAT REGARDLESS OF YOUR COMMUNICATION PREFERENCES, WE MAY STILL NEED TO CONTACT YOU FOR EMERGENCIES AND SERVICE MESSAGES

Main language spoken at home if English is not your first language (optional but this helps us in supporting your child/ward):*

Will you need an interpreter?*

Yes
No

Are you are happy for us to contact the child/young person directly when they are over 14:*

Yes
No

Young Carer Mobile*

Young Carer Email*

Do you consent for us to share this application information with professionals/ school / college*

Yes
No

Privacy Policy

Please review our privacy policy which can be found on the following page: https://www.actionforcarers.org.uk/privacy-policy/

Consent*

I agree to the privacy policy.

Parent/ Guardian Name:*

First Last

Date*

Name

This field is for validation purposes and should be left unchanged.

Register a young carer

Young Carer Registration Form

Surrey Young Carer Referral Form

YOUNG CARERS DETAILS:

PARENT/GUARDIAN DETAILS:

REFERRER DETAILS:

School/Health/Care Professional referring please complete section below

SCHOOL/COLLEGE:

About who you care for:

Agency or School to complete this section:

Parent/Legal Guardian to complete this consent section:

Privacy Policy

Please review our privacy policy which can be found on the following page: https://www.actionforcarers.org.uk/privacy-policy/