Register of Interest to attend All Wales Carers Assembly 2017

By completing this form you are registering your interest.  Applications will be dealt with on a first come, first served basis, based on your Assembly Members local or regional seat.  If someone has already registered and taken your local seat you will be placed on a reserve list and may need to take a seat outside your region.  This is not confirmation that you will have a place.  Confirmation will be sent to you in due course.  Please ensure that you complete all the questions, paying particular care to your e-mail contact details.

* 1. Title Mr/Mrs/Miss/Ms/ Doctor etc

* 2. First Name

* 3. Surname

* 4. House name/number and Street

* 5. Town where you live

* 6. Other address line

* 7. Local Authority area

* 8. Postcode

* 9. Email address

* 10. Contact telephone number

* 11. Are you currently a member of Carers Wales/Carers UK?

* 12. Do you wish to communicate in the Welsh language?

* 13. Do you have any disability/dietary or other requirements to enable you to participate?

* 14. If you are travelling out of reasonable daily travelling distance, (over 2 hours as an example) will you require overnight accommodation?  If yes we will get in touch with you to discuss.