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Home: Community full menu: Care and support: Carers

Kirklees Carers Emergency Card

Carers Gateway - November 2010
carers.gateway@kirklees.gov.uk

Registration Form

To help us ensure that we are able to give the person you look after the most appropriate help and support should there be an emergency, please give as much information as you can about yourself and the person you care for. Please fill in all boxes marked with *.

About you, the Carer

Your First Name*

Your Last Name*

Title

Other

Your Email Address

Your Address*

Number & Street/ Name
Area
Town
Postcode*

Telephone Area Code*

Telephone Number*

Date of Birth

Ethnic Origin (optional)

What is your relationship to the person you look after ?* (e.g. father, mother, not related)

Does this person live with you ?*

Yes

No

About how many hours a week do you spend caring for him / her ?

Hours per week

When do you give this care ?

Day

Night

Both

Are you in employment ?

Yes

No

Tell us about the kind of care you give to the person you look after.
Please click the relevant boxes and add any other information which might be helpful.


Meals and feeding
Preparing meals	Feeding	Which meals ?

Medication
Giving medication	What kind of medication ?	Where is it kept ?

Bathing/Washing/Dressing
Bathing / washing	Dressing	Taking to the toilet

Social contact
Friendship / support	Trips out	Just keeping an eye on him / her

Other care
Shopping	Cleaning	Getting round the house

If there is anything else you think we might need to know in an emergency, please explain below. Please give as much detail as you can.

Would you like to receive information about the Kirklees Carers Network ?

Yes

No

Would you like to receive information about Kirklees Carers Gateway?

Yes

No

About the person you look after

First Name	Last Name

Address	Postcode
House no & street Area Town
Telephone Area Code	Telephone Number

Date of Birth	Ethnic Origin (optional)

Please name and/or describe the disability, illness or condition of the person you look after

You may care for other people who also need to be contacted. If so, please fill in the following box.

Other contacts

It may help us to know about other people who might be able to help in an emergency. You need to get their permission to give us their details. It will also help them to know you carry a Carers Emergency Card and what it is for.

Is there anyone else involved in caring for this person who we should contact ?Yes No
If Yes, please give details

First Name	Last Name

Relationship to cared for person

Address	Postcode
Street Area Town
Telephone Area Code	Telephone Number
Home: Code	Number
Work: Code	Number
If there is anyone else we should know about, please give details. For example, is there a neighbour who holds a key so that we can get into the house of the person you look after if we have to ?
First Name	Last Name

Relationship to cared for person

Address	Postcode
Street Area Town
Telephone Area Code	Telephone Number

We may find it helpful to speak to the doctor or social worker of the person you look after. Please give details (optional).
Name of GP of the person you care for	Telephone Area Code	Telephone Number

Name of their Social Worker (if there is one)	Telephone Area Code	Telephone Number

Thank you for your co-operation. Please select 'Send Form' below to send your details


The Kirklees Carers Emergency Card is jointly funded and sponsored by Kirklees Adult Services and the Calderdale and Kirklees Health Authority. Privacy statement. This information will be used to ensure that Kirklees Adult Services provide you with help and support appropriate to your needs. It will not be used for any other purposes without your consent.

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