Sandwell Carer Friendly ID Card Registration

Are you completing this on behalf of someone else?

Yes

Carer Details

First Name

Last Name

Date of Birth

Carer Situation

If you are under 18, have you received permission from a Parent / Guardian to receive the card?

YesNo

Phone Number

Please check this is correct before submission

Your Address

We will send you Carers Card to this address

What is your Post Code?

Carer Organisation

What type of Card are you applying for

When did you register as a carer with your local carers support service?

In Case of Emergency

On the reverse of each card, we will record your ‘In Case of Emergency’ (ICE) contact details. This is the person who will be called if anything happens to you, e.g. your partner’s name & number, a relative or friend’s name & number. If you do not have anyone who could be emergency contact, please give the name and contact number of your GP practice.

Full Name

Contact Number

Please make sure this is a number for your emergency contact

Card Setup

The picture needs to be a head and shoulders photo that you are comfortable using on the front of the card

Please Attach an Image here

If you are completing this on behalf of a carer, please complete the following:

Your Name

Your Organisation

Your Contact Number

Your Email

Please tick this box to say that you have read and understood the privacy statement

Yes, I have read and understood the privacy statement

Contact Information