Carer Name:

Carer Address:

Carer Contact Number:

Carer Email Address:*

Carer PPS Number:

Carer Date of Birth:

Carer Next of Kin Name / Emergency Contact Name:

Carer Next of Kin Number / Emergency Contact Number:

Carer GP Name:

Carer GP No:

Are you in receipt of any of the following payments? (Please tick if applicable):-

Carers Allowance

Carers Benefit

Respite Care Grant

Not in receipt of any payment

Other (please give details):

What training do you feel you need to support you in your caring role? (Please see attached sheet for more details)

City & Guilds Care in the Home Training
FETAC Level 5 Practical Home Care Skills Training
Patient Moving & Handling Training
Stress Management Training
Personal Development Training (via online learning)
Workshops on relevant topics (please give details below)

What other training do you feel would be of most benefit to you as a Carer?

What time of day suits you for training. Please tick as appropriate.

Morning
Afternoon
Evening
Don't Mind

Do you have any other comments you wish to make or is there anything else you would like to advise us of in advance of any training course? If so, please give details.

It is important that we know a little about the person you are caring for so that our training can take account of any difficulties you might be experiencing. Please answer the following questions about the person you are caring for:-

Name:

Address:

Age:

PPS Number:

Medical Condition / Diagnosis / Illness (Helps us tailor training course to meet your needs)

What training would make caring for this person and their condition easier for you?