Register with us

The SIGNAL carers support service is the main port of call for Carers in Bracknell Forest.

In Bracknell Forest SIGNAL supports adults caring for adult residents of Bracknell Forest. Including young carers approaching adulthood and carers of disabled children approaching adulthood, with confidential, impartial information, understanding and assistance. The service is free to use.

Please complete the registration form below to register with us. Once your completed form is received we will contact you as soon as possible to discuss your individual circumstances so that we can tailor our support to suit your needs.

Before completing this form, please read our data protection policy as you will be asked at the end of the form to confirm that you have read it and that you agree to it.

As carers we know your busy people, the more questions you answer below the better as they help us to tailor our support to you. However you do not have to complete every question and please only tell us what you are comfortable with sharing. As a minimum please provide your name, phone number or email so that we can make contact with you.

YOUR DETAILS – Name

First

Last

Telephone Number

Email

Address

Are you a carer?

• Yes

If you are not a carer, please tell us why you are signing up?

For example; Ex-Carer, Professional

What gender do you identify with?

• Female
• Male
• Other

Please enter your gender if you selected other above

Date of Birth

Do you have a disability or health condition?

• Yes
• No
• Prefer not to say

Please tell us more about your disability/health condition if you wish to:

Describe the impact, if any, on your caring role?

What GP Surgery are you registered with?

Can we tell your GP Surgery you are a carer?

• Yes
• No

What is your ethnicity?

• Arab
• Asian / Asian British: Bangladeshi
• Asian / Asian British: Chinese
• Asian / Asian British: Indian
• Asian / Asian British: Pakistani
• Asian / Asian British: Any other Asian / Asian British Background
• Black / Black British: African
• Black / Black British: Caribbean
• Black / Black British: Any other Black / Black British Background
• Gypsy, Roma or Traveller
• White: British / English / Welsh / Scottish / Northern Irish
• White: Irish
• White: Any other White Background
• Any other ethnic group
• Prefer not to say

Ethnicity: Mixed / Multiple ethnic groups: please specify

COMMUNICATION – How should we contact you? (please select all that apply)

• Email
• Post
• Telephone
• Other

Please tell us how we should contact you if you selected other above

How should we NOT contact you? (please select all that apply)

• Email
• Post
• Telephone
• Other

If your details change or you would like to update your communication preferences please contact us.

Please tell us how we should NOT contact you if you selected other above

Do you need information provided in an alternative format?

• No
• Yes

(Easyread, large print, audio etc.)

If you said yes above please tell us what format?

What is your primary/main communication language?

(English, British Sign Language, Polish etc.)

Do you need information provided in an alternative language?

• No
• Yes

(Nepali, Polish, Urdu etc.)

If you said yes above please tell us what language?

Is there anything else you would like to tell us that may have an impact on your caring role?

(religion, culture, relationship status, family etc.)

Information about the person you care for – Name

First

Last

If you care for more than one person, please let us know when we contact you.

What is the main disability / condition of the person you care for?

• Autism
• Dementia
• Drugs/alcohol needs
• Frailty (old age)
• Learning disability
• Long term illness
• Mental health needs
• Physical disability
• Terminal illness
• Other
• Not declared
• Don’t know
• Not applicable

What gender do they identify with?

• Female
• Male
• Other

If your details change or you would like to update your communication preferences please contact us.

Please enter their gender if you selected other above

Age band

• 17 and under
• 18-24
• 25-49
• 50-64
• 65-79
• 80+

If your details change or you would like to update your communication preferences please contact us.

Date of Birth

(if known)

What Local Authority does the person you care for live in?

• Bracknell Forest
• Other

Please enter their Local Authority if you selected other above

How did you hear about us?

• Community / voluntary sector organisation
• Event in the community
• Health professional
• Internet search engine
• Leaflet
• Poster
• Registered with SIGNAL previously
• Social care professional
• Social media
• Word of mouth
• Other

Please tell us how you heard about us if you selected other above

DATA PROTECTION *

• I acknowledge that I have read and agree to the data protection policy.

Submit