RM_StatsCarer's Registration FormBarnet Carers is a leading charity offering advice, information, emotional and practical support for all informal carers who live or work in the London Borough of Barnet.The Adult Carers Team assists carers over the age of 18 by providing a range of services such as Carer's Assessments, Counselling, peer support groups, regular support calls, training, and more.The Young Carers Team helps carers from the age of 5 to 17. Young people can access support in schools, mentoring, tutoring and benefit from activities led by partners from different organizations across the Borough.If you, or someone you know, might benefit from our help and support don’t hesitate to contact us. We are here to help. TitleSelect an optionMrMrsMsMissHow do you like to be addressed.First NameLast NameThis is your last or family name.How would you like us to address you?How would you like us to address you. This could be the name you are used to or whether you would prefer us to be more formal.Date of birthDon't worry, we will not be sharing your age with anyone, we just need it for our records and to make sure that we are providing you with appropriate information.Address Address Line 1 Address Line 2 City State or Region Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and the McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iraq Iran Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Post Code Phone NumberMobile NumberEmailYour email, that will be included in our mailing list.GenderSelect an optionMaleFemaleTransgenderGender NeutralOtherPrefer not to sayWe take note of the gender of the people we offer Carers Assessments so that we can make sure that we are being fair and respecting people's identities.ReligionSelect an optionChristianCatholicJewishMuslimHinduSikhBuddhistOtherAtheistNo religionPrefer not to sayWhat is your preferred language?We will try and get someone to speak to you who can speak your language. This is not always possible and if necessary we will organise for an interpreter.Do you need an interpreter? Yes No Average hours of caring per week:Select an optionUnkown0-1010-3030-5050-100100+How many hours per week do you spend in your caring role? Now we are going to ask you some questions about the person you care for. This is so that we can get a good idea of the care you are offering and can make sure that your carers action plan fits you as well as it can.Title of the person you care forFirst name of the person you care forLast name of the person you care forAddress of the person you care for Address Line 1 Address Line 2 City State or Region Zip Cared for date of birthGender of person you care forSelect an optionMaleFemaleTransgenderPrefer not to sayWe take note of the gender of the people we offer Carers Needs Assessments to so that we can make sure that we are being fair and providing services to all who need them,What is your relationship to the person you care for?Select an optionSonDaughterPartnerSiblingSpouseParentFriendNeighbourOther relativeWhat condition is the person you care for affected by? Autistic Spectrum Disorder (ASD) Learning Disability Cancer Dementia Mental Health Issue Physical Disability Drug/Alcohol Dependency Frail Through Aging OtherTick as many as apply. How did you hear about Barnet Carers?For example, your GP, Social Worker, other charitable organizations, friends, online research...I give consent for my details to be held on Database Yes No Please confirm that you have given consent for the information provided on this form to be securely and confidentially stored on our database.Admin *Don't worry about this field! This is just the admin email. Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.