Thank you wanting to register with Halton Carers Centre, If you could take a few moments to complete our details form.  Once we receive this online a Carers Support Worker will be in touch with you within 10 days to complete our full registration form.

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* 1. Carers Name

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* 2. Carers Address

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* 3. Carers Contact Number

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* 4. Carers email address

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* 5. How did you hear about Halton Carers Centre?

The person you care for details

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* 6. Their name

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* 7. Their Date of Birth

Date

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* 8. Their relationship to you

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* 9. What is their health condition/diagnosis/disability

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