Welcome to Blackpool Carers Centre!

Carer Registration Form

Please fill in this short form with your details and Blackpool Carers Centre will contact you within 2 working days. Fields marked with an * must be filled in.

Carer Details

Carer Title

Carer Name*

Date of Birth

I Care For My

Caring Role

Carer Contact Information

Telephone*

Email

Contact Method

  • If you prefer not to be contacted by telephone, please choose another method here.

Carer Address Details

Carer Address

Referrer's Details

Self Referral

  • Do you wish to refer yourself?

Third-Party Referral

  • Are you a referring organisation?

Name of Referring Organisation

Contact at Referring Organisation

Referrer Contact Number

Carers' Consent

Carer Consent*

  • I agree to Blackpool Carers Centre holding my information and I know I can view the data on my file by request.
    I understand that my details may be shared with Blackpool Carers Centre partner organisations and funders to improve information and services.
    (please tick box to confirm)

Young Carer and Parent/Guardian Consent

  • Is the young carer aware of this referral?
  • Is the young carers' parent/guardian aware of this referral?

Carer Registration Form

    Thank you for registering with the Blackpool Carers Centre and providing us with your details. We will process your application and someone from the Blackpool Carers Centre will be in contact with you within 3 working days.

    If you need to contact the Blackpool Carers Centre please telephone 01253 393748 or email admin@blackpoolcarers.org

    Please visit our website to find lots of useful information for carers at http://www.blackpoolcarers.org/