Application for Carers Emergency Card

In line with General Data Protection Regulations (GDPR) the information given on this form will be treated in the strictest confidence by both Worcestershire Association of Carers and Redditch Lifeline.

If you have any difficulty filling in this form and would like support, are unsure about anything or would like further information please call us on 0300 012 4272. We are here to help.

ABOUT YOURSELF (THE CARER)

Title

First name

Surname

Gender

Male

Female

Address

Post Code

Home Tel Number

Mobile Tel Number

Work Tel Number

ABOUT THE PERSON(S) YOU CARE FOR

Person One:

Title

First Name

Surname

Date of Birth

Address

Postcode

Telephone Number (if different to yours)

Main language spoken

Gender

Male

Female

Any Communication Difficulties?

Any Illnesses/Disabilities?

Name and Tel Number of their Doctor's Surgery?

Are there any special instructions we should know about in an emergency?

Person 2 (if applicable)

Title

First Name

Surname

Date of Birth

Address

Postcode

Telephone Number (if different to yours)

Main language spoken

Gender

Male

Female

Any Communication Difficulties?

Any Illnesses/Disabilities?

Name and Tel Number of their Doctor's Surgery?

Are there any special instructions we should know about in an emergency?

DETAILS OF PEOPLE (NOT CARER DETAILS) WHO CAN BE CONTACTED IN AN EMERGENCY

Emergency Contact One:

Name

Address

Home Tel Number

Mobile Tel Number

Work Tel Number

Emergency Contact Two:

Name

Address

Home Tel Number

Mobile Tel Number

Work Tel Number

If you have key safe details that you would like to be kept on record, please contact us directly via phone or email and we can take those securely. Thank you.

I confirm that all persons named on this form consent to their information being held by Worcestershire Association of Carers and Redditch Lifeline in line with General Data Protection Regulations.

Signature

If the person you care for would like a card, please tick here.