Title First Name* Preferred name if different Last Name* Address 1* Address 2 Town County Postcode* Email Address Telephone: Home Telephone: Other daytime contact* Telephone: Mobile Date of Birth* D D M M Y Y Y Y GP Surgery Name* I am happy for you to let my GP know that I am a carer.* (This will help your GP surgery to make sure you are looking after your own health). Yes No The following questions are optional but the information you supply will help us better understand the needs of all family carers so that we can tailor our support to you. We will also use this information to monitor the services we provide. Responses to these questions remain confidential. Individuals will not be identified and personal details will not be published. How long can you leave the person you care for? Never 1 2 Hours Up to 4 Hours Up to 8 Hours Overnight – Are you registered disabled? Yes No Do you have any kind of a health condition requiring ongoing medical attention? Yes No Please state your ethnic origin. (This would help us determine whether or not we are meeting the needs of all carers) Asian or Asian British – Mixed - White & Black African Any other Asian background Pakistani Mixed - White & Black Any other Black background Black or Black British - African Caribbean Any other ethnic group Black or Black British - Traveller Any other mixed background Caribbean White - British Asian or Asian British – Chinese White - Irish Bangladeshi Do not wish to disclose Asian or Asian British Indian White Other – – Mixed - White & Asian Please tell us where you heard about the What If? Plan and Carers Emergency Card? Information we need about the person you care for:
Title First Name* Preferred name if different Last Name* Address 1* Address 2 Town County Postcode* Email Address Telephone: Home Telephone: Other daytime contact* Telephone: Mobile Date of Birth* D D M M Y Y Y Y GP Surgery Name* I am happy for you to let my GP know that I am a carer.* (This will help your GP surgery to make sure you are looking after your own health). Yes No The following questions are optional but the information you supply will help us better understand the needs of all family carers so that we can tailor our support to you. We will also use this information to monitor the services we provide. Responses to these questions remain confidential. Individuals will not be identified and personal details will not be published. How long can you leave the person you care for? Never 1 – 2 Hours Up to 4 Hours Up to 8 Hours Overnight Are you registered disabled? Yes No Do you have any kind of a health condition requiring ongoing medical attention? Yes No Please state your ethnic origin. (This would help us determine whether or not we are meeting the needs of all carers) Any other Asian background Any other Black background Any other ethnic group Any other mixed background Asian or Asian British – Bangladeshi Asian or Asian British – Indian Asian or Asian British – Pakistani Black or Black British - African Black or Black British - Caribbean Chinese Do not wish to disclose Mixed - White & Asian Mixed - White & Black African Mixed - White & Black Caribbean Traveller White - British White - Irish White – Other Please tell us where you heard about the What If? Plan and Carers Emergency Card? Information we need about the person you care for:
What-If-plan-full-hardcopy-v10-2.docx