zendesk test | Action for Carers

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

Email (Enables us to send information to you)
Post (Enables us to send information to you)
Phone (For telephone assessments and arrange appointments when needed)
Text

You can choose how we keep in touch with you. It helps us if you can select as many as possible of the options below.

If we try to contact you on a landline number and cannot get hold of you, please check the below box IF YOU DO NOT wish for us to leave a generic answerphone message.

I do not wish for Action for Carers Surrey to leave a generic message on my answerphone.

Please note that if there is an emergency or any last minute changes to an event you are booked on we may need to phone you. Please tick one*

I consent to be contacted by phone under these conditions
I DO NOT consent to be contacted by phone under any circumstance

Carer First Name*

I consent to the processing of data as I have inputted in this form

Carer Last Name*

Your ID Number with Action for Carers Surrey (If known)

Address

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

Date of Birth

Email (If you have consented to be contacted in this way)

Phone (If you have consented to be contacted in this way)

Mobile (If you have consented to be contacted in this way)

Sharing Information: If you are receiving a service from us, we may ask you to consent to information about you being shared with other professionals or organisations to help provide you with support, where appropriate, either now or in the future. We will ask you at the time if such a referral is deemed appropriate. We will not share information without your consent except where disclosure is necessary for safeguarding purposes or as required by law. We also raise awareness of carer issues both locally and nationally. If you would like to participate in consultations and campaigns to help improve services for carers, please tick the boxes above:

Action for Carers (Surrey) - Consent to Process Personal Data*

I confirm that I have read the below statement

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. You can find our Privacy Policy at www.actionforcarers.org.uk and we recommend that you read it before you complete this form. If you have any questions about this form, or about how we use your personal data, please contact us Telephone: 0303 040 1234 or call 01483 302748 and ask for the Data Protection Officer. Email: [email protected] Post: FREEPOST Action for Carers Surrey As a core part of our service we will send out newsletters, invitations to carer support groups, forums and other carer related events and activities, which we run. We also from time to time seek your views to help inform our service provision and compile anonymised statistical data and case studies for commissioning and research purposes. The services that we deliver are funded by local councils. Action for Carers is obligated to provide information to the councils so that they can measure our performance and analyse and improve carer services under the Government’s “National Carers Action Plan 2018-2020”. To do this, Action for Carers may provide non-identifiable aggregated data to the council (e.g. % in ethnicity brackets etc.). Action for Carers may also provide to the council individual base level data about you (e.g. name, date of birth etc.) but will not pass on information about your particular situation. If you object to any information related to you being passed on to the council, then please inform us and you will be excluded from all data provided to the council.

Consent*

I confirm I am the named Carer on this form

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

I confirm

Comments

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Contact preferences and data agreement