Register with us

Name*

Your title First Last

Date of birth*

Please note that if you are under 18, an adult (parent, guardian or professional) will need to register you with our young carers service.

DD

MM

YYYY

Are you over 18?*

Yes
No

SORRY! But we can't take referrals from under 18s on this form.
If you’re under 18, find out about our service for young people here: Surrey Young Carers or give our team a call on 01483 568269

Do you live in Surrey?*

We can only support carers in Surrey

Yes
No

Unfortunately we can only support carers in Surrey but you might find this page with other carer support services useful:

Other charities supporting carers

Address*

Street Address Address Line 2 Town/city County Post code

You can choose how we keep in touch with you.

Phone can be particularly helpful as it enables us to follow up your registration with a call.
Please confirm if we may contact you in the following ways:

Telephone / mobile*

Please confirm whether or not we can contact you by phone.

Yes
No

Your phone number

Use your mobile or home number, whichever is best for you.

The best time to call

Please indicate if you would prefer us to call at certain times

Mornings
Afternoons
Tuesday/Wednesday evenings (up until 6pm)
Any of the above

Text*

Please confirm whether or not we can contact you by text message.

Yes
No

Your mobile number

Please enter the mobile number we should text you on.

Email*

Please confirm whether or not we can contact you by email.

Yes
No

Your email address

Post*

Please confirm whether or not we can contact you by post.

Yes
No

Ethnicity

This is optional but allows us to provide statistical data.

I am*

Male
Female
Other gender
Prefer not to say

Are there any other carers in the house, including children and young adults?*

Yes
No
Not sure

Second carer

Can you tell us the age of the second carer in the house

Are there more than two carers in the house

Yes
No

Third carer

Can you tell us the age of the third carer?

Do you, yourself have any disabilities or illness you would like us to know about?*

Yes
No

info on health considerations

Do you have any religious or cultural considerations you would like us to know about?*

Yes
No

Info on religious and cultural considerations

Do you have any specific communication needs, e.g. language, large print, audio, translation?*

Yes
No

Info on communication needs

Do you physically help the person you care for? E.g. help them stand up, lift their legs into bed, push their wheelchair or help them in/out of a car.*

Yes
No

About who you care for

Optional – you don’t have to complete this section, but it will help us understand how best to support you.

Age of main cared for person

Please pick the age range of the main person you care for.

Condition of main cared for person

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

Do you look after anyone else?*

Yes
No

Age of second cared for person

Please select the age of the second person you care for

Condition of second looked after person

Please select the disability or condition of the second person you look after from the list below.

Name of GP Surgery / Practice

Does your GP know you are a carer?

Yes
No
Not sure

Are there any other agencies involved with your caring situation, such as Social Services, Crossroads Care, etc.?

Yes
No

Other agencies

Can you tell us why you want to register with us?

How did you hear about Action for Carers?

We offer opportunities to take part in consultations and campaigns to help improve life for other carers.

If you are interested in hearing about these, or our fundraising, please tick below. You can change your preferences at any time – by emailing dpo@actionforcarers.org.uk, phoning 01483 302748 or by writing to FREEPOST, Action for Carers Surrey.

Consultations and campaigns on issues related to carers
Action for Carers Surrey fundraising activities or events

I am the named carer on this form*

Confirm

I agree to Action for Carers processing my data and I have read the Privacy Policy. Please tick to confirm*

Agree

Comments

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

Why do I need to register?

Registration Form

Registration Form

SORRY! But we can't take referrals from under 18s on this form.
If you’re under 18, find out about our service for young people here: Surrey Young Carers or give our team a call on 01483 568269

Unfortunately we can only support carers in Surrey but you might find this page with other carer support services useful:

You can choose how we keep in touch with you.

About who you care for

Why do I need to register?

Registration Form

Registration Form

SORRY! But we can't take referrals from under 18s on this form. If you’re under 18, find out about our service for young people here: Surrey Young Carers or give our team a call on 01483 568269

Unfortunately we can only support carers in Surrey but you might find this page with other carer support services useful:

You can choose how we keep in touch with you.

About who you care for

SORRY! But we can't take referrals from under 18s on this form.
If you’re under 18, find out about our service for young people here: Surrey Young Carers or give our team a call on 01483 568269