Carer Registration Form - Birmingham Carers Hub

Your Details

Are you completing this on behalf of someone else?

Yes

Fields marked with a * must be completed

First Name

Surname

Title

Gender

Your Date of Birth

Please enter date as DD/MM/YYYY

Telephone Number

Mobile Number

If you do not have a mobile number, you can call 0333 006 9711 and register with our contact team instead

E-mail

If you do not have an email address, you can call 0333 006 9711 and register with our contact team instead

Address

City/Town

County

Post Code

Do you or the person you care for, pay your council tax to / or are receiving Council tax benefit from Birmingham City Council? Your address will be verified to confirm you are eligible for this service.

YesNo

Do you live with the person you care for?

Information about your Caring Role

When did you start your caring role?

Please Enter Date as DD/MM/YYYY

How many hours of care do you provide each week?

Are you getting any additional support from other organisations, if so where from?

What is the main support you provide for the person you are caring for?

Do you have a Health Condition/ Disability of your own?

Please Give Details of your Health Condition / Disability (If applicable)

Is your GP aware that you are caring for someone else?

NHS number

Birmingham Carers Hub works with the NHS and Local Authorities to provide joined-up support. Your NHS number helps us securely match your details with existing records. This is optional and your information is always kept safe and confidential. You can visit https://www.nhs.uk/nhs-services/online-services/find-nhs-number/ to find your NHS number

Who you care for

Please provide some details regarding the person or person’s you care for.

Person's First Name

Person's Last Name

Person's DoB

Please enter date as DD/MM/YYYY

Person's relationship to you

Person's Address

Person's Post Code

What is their primary health condition / disability?

Do they have any other Health Conditions/ Disabilities that we should be aware of?

Any child or young person aged from birth to 18 years in Birmingham with a special educational need and/or disability can be on the Birmingham Disabled Children’s Register. If your child is under 18, Would you like to register this person to the disabled children's register?

Yes PleaseAdding your child’s name to the Birmingham Disabled Children’s Register will help our commissioners Birmingham Children’s Trust to understand more about the needs of children with disabilities and be able to plan better services in Birmingham in the future. Only Parent Carers and guardians can add their children to the register; it is completely voluntary and you can remove your details at any time.

We'll need some additional information to add your child to the disabled children register

Your Ethnicity

The Childs Gender

The Child's Ethnicity

You may be asked to provide evidence of any disability and/or condition. What evidence would you be able to provide on request (for example Benefit Entitlement letters, Consultant or Health Professional letters, Support Service letters, Statement of Educational Needs)?

Being the parent or carer of a child with an additional need and/or disability and enrolled on the Disabled Children’s Register may allow you to receive a Max Card. Max Cards give you FREE or discounted entry to literally hundreds of fantastic family friendly attractions.

Please tick here if you would like a Max CardPlease allow 30 days to receive your Max Card from the date of your application.

If you have someone else you are caring for, you can provide some details here:

Person 2's First Name

Person 2's Last Name

Person 2's DoB

Please enter date as DD/MM/YYYY

Person 2's relationship to you

Person 2's Address

Person 2's Post Code

What is their primary health condition / disability?

Do they have any other Health Conditions/ Disabilities that we should be aware of?

Any child or young person aged from birth to 18 years in Birmingham with a special educational need and/or disability can be on the Birmingham Disabled Children’s Register. If your child is under 18, Would you like to register this person to the disabled children's register?

Yes PleaseAdding your child’s name to the Birmingham Disabled Children’s Register will help our commissioners Birmingham Children’s Trust to understand more about the needs of children with disabilities and be able to plan better services in Birmingham in the future. Only Parent Carers and guardians can add their children to the register; it is completely voluntary and you can remove your details at any time.

We'll need some additional information to add your child to the disabled children register

Your Ethnicity

The Childs Gender

The Child's Ethnicity

You may be asked to provide evidence of any disability and/or condition. What evidence would you be able to provide on request (for example Benefit Entitlement letters, Consultant or Health Professional letters, Support Service letters, Statement of Educational Needs)?

Being the parent or carer of a child with an additional need and/or disability and enrolled on the Disabled Children’s Register may allow you to receive a Max Card. Max Cards give you FREE or discounted entry to literally hundreds of fantastic family friendly attractions.

Please tick here if you would like a Max CardPlease allow 30 days to receive your Max Card from the date of your application.

Support Required

Where did you hear about the Birmingham Carers Hub?

Which Carer project referred you to the Birmingham Carers Hub?

What Support or Information do you think you need?

I would like to join Carers Voice to be part of Carer questionnaires and focus groups

Yes

I have read and agree to the Data Protection and Privacy Statement (View)

Agree

If you are completing this on behalf of somebody else, we'd like some details about you

Your Name

Your Email

Your Organisation

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