Dudley Young Carer Registration Form
Personal Information
Fields marked with a * must be completed
First Name
Last Name
My Date of Birth
Please enter date as DD/MM/YYYY
x
Gender
Please select...
Female
Male
Transgender FTM
Transgender MTF
Other
Prefer Not To Say
Your Ethnicity
Please select...
White: British
White: Irish
White: Traveller of Irish or Gypsy Heritage
White: European
White: Any Other White Background
Mixed / Multiple ethnic group: White and Black African
Mixed / Multiple ethnic group: White and Black Caribbean
Mixed / Multiple ethnic group: White and Asian
Mixed / Multiple ethnic groups: Other Mixed Background
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Bangladeshi
Asian or Asian British: Any other Asian Background
Black or Black British: African
Black or Black British: Caribbean
Black or Black British: Any other Black background
Other ethnic group: Chinese
Other ethnic group: Arab
Any other ethnic group
Prefer not to say
Address
Address
City/Town
County
Post Code
Contacting you
Mobile Number
Do we have permission to send you texts or messages on Whatsapp?
Yes
E-mail
Do you have regular internet access outside school?
Yes
No
My School or Job
What School or College do you go to?
Are you Working or Volunteering?
Yes
No
Is your work or volunteering
Full Time
Part Time
Contact Name and Phone Number at Phone/College/ Work
About My Parent/Guardian
Name of My Parent/Guardian
How do you know them? (e.g. Mom, Dad, Aunt)
Please select...
Mother / Mom
Father / Dad
Guardian
Brother
Sister
Carer
Grandmother
Grandfather
Other Family Member
Aunt
Uncle
Their Address (If different from mine)
Their Phone Number
If you do not have a mobile number, you can call 0333 006 9711 and register with our contact team instead
x
Their E-mail
If you do not have an email address, you can call 0333 006 9711 and register with our contact team instead
x
Does my Parent/Guardian give permission for me to receive help from this service?
Yes
No
We will be sharing your assessment with your parent/guardian, are you happy to allow us to do this?
Yes
No
Understanding My Caring Role
Who do you care for?
What is the reason for providing care?
Please select...
Long-term illness (like a parent or sibling being sick for a long time)
Physical or learning disability (helping someone who has trouble moving around or learning)
Mental health problems (like a family member feeling very sad, anxious, or stressed)
Issues with drugs or alcohol (caring for someone who struggles with substance use)
Looking after an elderly relative (helping an older family member who can’t do things on their own)
Short-term illness or injury (caring for someone who is temporarily hurt or sick)
Looking after younger siblings (when a parent isn’t able to take care of them)
Household chores and responsibilities (like cooking, cleaning, or shopping for the family)
Person's relationship to you
Please select...
Aunt
Brother
Child
Cousin
Coworker
Daughter
Employee
Employer
Family
Father
Friend
Grandchild
Granddaughter
Grandfather
Grandmother
Grandson
Husband
Mother
Nephew
Niece
Parent
Partner
Sister
Son
Spouse
Uncle
Wife
Cared For
Person's Date of Birth
Please enter date as DD/MM/YYYY
x
My Caring Activities
How often do you do the following:
1 = Never
2 = Occasionally
3 = A lot of the time
Domestic Tasks (e.g., cleaning, cooking, washing dishes)
Household Management (e.g., shopping, lifting heavy things)
Personal Care (e.g., helping with dressing, washing, mobility)
Emotional Care (e.g., keeping company, providing supervision)
Sibling Care (e.g., looking after siblings)
Financial and Practical Management (e.g., handling bills, interpreting)
Medication (e.g., collecting prescriptions, giving/reminding to take medication)
Impact of Caring on My Life
How does caring make you feel? (1 = Very negative, 5 = Very positive)
1
2
3
4
5
Does caring affect your schoolwork? ((1 = Not at all, 5 = Very much)
1
2
3
4
5
Have you missed school because of caring?
Yes
No
Have you been late to school because of caring?
Yes
No
Does caring affect your social life? ((1 = Not at all, 5 = Very much
)
1
2
3
4
5
Do you need more time for yourself? (1 = Not at all, 5 = Very much)
1
2
3
4
5
Does caring affect your physical health? (1 = Not at all, 5 = Very much)
1
2
3
4
5
Does caring affect your emotional health? (1 = Not at all, 5 = Very much)
1
2
3
4
5
What is one thing you like about caring?
What is one thing you dislike about caring?
Is there anything about caring that upsets you?
What would make caring easier for you?
My Goals and Support Network
What do you hope to do in the future?
How much does your caring role affect these plans? (1 = Not at all, 5 = Very much)
1
2
3
4
5
Family members, friends, or professionals who help you are...
How often do you talk to them about your caring role? (1 = Never, 5 = Very often)
1
2
3
4
5
What professionals help you with your caring role (e.g., Teacher, social worker)
How helpful is this support? (1 = Not helpful, 5 = Very helpful)
1
2
3
4
5
Do you know of any services that could help but you are not currently using?
Completing your Registration
What support would you like to find out about from the Young Carer service?
I confirm that I have read and agree to the privacy policy
I understand how my data will be used and that I can withdraw my consent at any time
Contact Information