Register With Carers Bucks

Are you looking after someone who cannot manage without you because they are ill, frail or disabled? If so, you are a carer and Carers Bucks is here for you.

Complete our registration form below to register with Carers Bucks and make use of our free services, including information, advice, guidance, emotional support and a listening ear. Once we have received your form, one of our Support Workers will follow up with a telephone call which will give you the opportunity to discuss your caring role in detail. The Support Worker will work with you to resolve any issues or problems you may have in your caring role. If you have an urgent request please highlight this on the form.

For information on how Carers Bucks stores and uses your personal data, please see our Privacy Notice.

    First name (required)

    Last name (required)

    Your date of birth (required)

    Are you aged 18+? (required)
    Yes
    If you are aged 17 or below, please fill in our Young Carers referral form.

    Gender

    Is your gender identity the same as it was given at birth?

    Sexual Orientation

    Ethnicity

    House name/no. (required)

    Street (required)

    Postcode (required)

    Your email address (required)

    Phone number (required)

    How many people do you care for? (required)

    Name of the person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Name of the first person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Name of the second person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Name of the first person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Name of the second person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Name of the third person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Name of the first person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Name of the second person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Name of the third person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Name of the fourth person you care for? (required)

    Their date of birth (required)

    What is their illness/disability? (required)
    ElderlyDementiaMental IllnessPhysical DisabilityLearning DisabilityOther

    Their relationship to you? (required)

    Are they currently in hospital?

    Further information request

    How did you hear about Carers Bucks? (required)