Digital Membership Form

Membership to North Lanarkshire Carers together is completely free and open to any carer living within North Lanarkshire. You will receive our twice yearly newsletter and be invited to our conference, annual events and consultations as your views are important to us. Together we can be a potent force for change.

First Name

Surname

Date of Birth

Gender Gender Male Female

Telephone Number

Confirm Email Address

Postal Address

Do you wish to be included on our email list to receive e-bulletins from North Lanarkshire Carers Together? Do you wish to be included on our email list to receive e-bulletins from North Lanarkshire Carers Together? Yes No

What is your Ethnic Group? What is your Ethnic Group? White Mixed/Multiple Asian/Asian Scottish/Asian British African/Caribbean/Black I Prefer Not To Answer Other

Please give details if you answered other

How Many People do you care for?

Date of Birth of the person you care for?

Do you live with the person you care for?

Are you their only carer?

What areas of support are of interest? What areas of support are of interest? Your Right to a Carers Assessment Carers Support Young Carers Support Health and Social Work Services SDS (Self-directed support) GP Register Short Breaks/Respite Local Support Groups Care and Repair services Condition Specific Information Other

Please give details if you answered other

Please click on the relevant boxes for information that you would like to receive Please click on the relevant boxes for information that you would like to receive Your Right to a Carers Assessment Carers Support Young Carers Support Health and Social Work Services SDS (Self-directed support) GP Register Short Breaks/Respite Local Support Groups Care and Repair services Condition Specific Information Other

Please give details if you answered other

Please use this space to give us more information if required:

Professional/Designation Only Professional/Designation Only If you are a professional/designation only and do not have a caring role but would like to sign up for membership please select this option.

Confirmation Confirmation I would like to become a member of North Lanarkshire Carers Together and agree to this application being stored in their database

Date

Information you provide to us on our membership form is stored securely on our database. We use this information to register you as a member and provide you with information you have requested. Membership includes an invitation to our AGM and Annual Carer Conference and we may also contact you with regards to carer consultations and events that may be of interest to you. North Lanarkshire Carers Together will treat your information as confidential and will only share information with your consent.