Dorset 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

Carer Organisation

Which Carer Service registered with

ID No / Reference from Dorset

Your Carer ID number can be found in the Carers Card letter/email sent to you from CRISP or Carer Support Dorset. If you can't find this, please contact them and ask for your ID number

What type of Card are you applying for

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

Postal Address

This is where we will send the carer card to. Please make sure this address is correct before submitting this form

Address Line 1

Address Line 2 (If required)

Town / City

Post Code

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

Would you like the digital card? (Please note you will need a smartphone and to have provided an email address above)

YesNo

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