zendesk test | Action for Carers

Please confirm the methods we may contact you by (please tick all that apply):*

Email
Post (Enables us to send information to you)
Phone (For telephone assessments and arrange appointments when needed)
Text

It helps us if you can select as many options as possible.

If we try to contact you on a landline number and can't get hold of you, please check the below box IF YOU DO NOT want us to leave a generic answerphone message.

I do not wish for Action for Carers Surrey to leave a generic message on my answerphone.

Please note that if there is an emergency or any last minute changes to an event you are booked on we may need to phone you. Please tick one*

I consent to be contacted by phone under these conditions
I DO NOT consent to be contacted by phone under any circumstance

First name*

I consent to the processing of data as I have inputted in this form

Last name*

Your ID Number with Action for Carers Surrey (If known)

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of birth

Email (If you have consented to be contacted in this way)

Landline phone (If you have consented to phone contact)

Mobile phone (If you have consented to phone contact)

Sharing Information: If you are receiving a service from us, we may ask you to consent to information about you being shared with other professionals or organisations to help provide you with support, where appropriate, either now or in the future. We will ask you at the time if such a referral is deemed appropriate. We will not share information without your consent except where disclosure is necessary for safeguarding purposes or as required by law. We also raise awareness of carer issues both locally and nationally. If you would like to participate in consultations and campaigns to help improve services for carers, please tick the boxes above:

Action for Carers (Surrey) - Consent to Process Personal Data*

I confirm that I have read the below statement

Our Privacy Policy explains why Action for Carers (Surrey) collects personal data, how we use it, who we may share it with, and sets out your rights in relation to your data. You can find our Privacy Policy at www.actionforcarers.org.uk and we recommend that you read it before you complete this form. If you have any questions about this form, or about how we use your personal data, please contact us, call 0303 040 1234 and ask for the Data Protection Officer, email [email protected] or write to FREEPOST Action for Carers Surrey. As a core part of our service we will send out newsletters, invitations to carer support groups, forums and other carer related events and activities, which we run. We also sometimes seek your views to help inform our services and compile anonymised statistical data and case studies for commissioning and research purposes. Our services are funded by Surrey County Council and we must provide them with information so they can measure our performance and analyse and improve carer services. To do this, Action for Carers may provide non-identifiable aggregated data to the council (e.g. % in ethnicity brackets etc.). Action for Carers may also provide to the council individual base level data about you (e.g. name, date of birth etc.) but will not pass on information about your particular situation. If you object to any information related to you being passed on to the council, then please inform us and you will be excluded from all data provided to the council.

Consent*

I confirm I am the named Carer on this form

I agree to Action for Carers processing my data and I have read the Privacy Policy. Please tick to confirm*

I confirm

Phone

This field is for validation purposes and should be left unchanged.

Contact preferences and data agreement