Carer Application - Carers Parliament 2016

1. Carers Parliament - Carer Application Form

100% of survey complete.

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The fifth Carers Parliament will be held on 2 November 2016. The event will be held at Heriot-Watt University, Edinburgh

If you complete this form you will be entered into the ballot for places. There will be two delegates from each of the 73 Scottish Parliamentary constituencies.

The ballot, conducted by carers on the Steering Group, will be held in late July with successful delegates informed in early August.

A small number of additional places have been reserved for carers who are contributing to the programme, for example as members of the steering group or speakers and to ensure minority groups and young carers are represented.

Some funding is available to support carers to attend. This will include travel and subsistence and, if required, accommodation and/or replacement care costs. If you are successful, we will ask you more about this.

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Please note: the event is open to carers and former carers only. This means people who provide unpaid care to family members, other relatives, partners, friends and neighbours of any age affected by physical or mental illness, disability, frailty or substance misuse.

I am a:

Carer

Former carer

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Title
(Required.)

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First name (Required.)

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Surname (Required.)

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Your address: (Required.)

Address 1

Address 2

Town

County

Post code

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Telephone or mobile number (Required.)

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Email address:

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Scottish Parliamentary Constituency
(Please choose from the list below. If not known, please leave blank and we will complete for you)

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How did you find out about the Carers Parliament? Tick all that apply.

Carers Scotland

Coalition of Carers in Scotland

Crossroads Caring Scotland

Minority Ethnic Carers Project (MECOPP)

Carers Trust Scotland

Scottish Young Carers Alliance

Shared Care Scotland

A local carers centre or service

A condition specific organisation such as the Huntington's Disease Association, MS Society etc.

Another voluntary organisation such as Age Scotland

MSP constituency office

Through social media e.g. Facebook or Twitter

Word of mouth

Other (please detail below)

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The data we collect in the form will be used solely for the purposes of the Carers Parliament including, if you are successful, to register you as a delegate, and for all applicants, to share a final report.

Otherwise your details will not be shared without your consent. However, we would like to keep you up to date with other developments, events for carers and information.

	Yes	No
Can we share your information with the other national carer organisations in relation to other RELEVANT events?	Can we share your information with the other national carer organisations in relation to other RELEVANT events? Yes	Can we share your information with the other national carer organisations in relation to other RELEVANT events? No
Can we contact you in future about other issues related to caring e.g. events, information or new materials?	Can we contact you in future about other issues related to caring e.g. events, information or new materials? Yes	Can we contact you in future about other issues related to caring e.g. events, information or new materials? No
Can we share your details with your local MSP?	Can we share your details with your local MSP? Yes	Can we share your details with your local MSP? No

Thank you for completing this application. The closing date for applications is 12 August 2016

If you are successful in the ballot to select delegates, we will contact you at the end of August.

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* Please note: the event is open to carers and former carers only. This means people who provide unpaid care to family members, other relatives, partners, friends and neighbours of any age affected by physical or mental illness, disability, frailty or substance misuse. I am a:

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* Title (Required.)

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* First name (Required.)

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* Surname (Required.)

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* Your address: (Required.)

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* Telephone or mobile number (Required.)

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* Email address:

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* Scottish Parliamentary Constituency (Please choose from the list below. If not known, please leave blank and we will complete for you)

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* How did you find out about the Carers Parliament? Tick all that apply.

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Please note: the event is open to carers and former carers only. This means people who provide unpaid care to family members, other relatives, partners, friends and neighbours of any age affected by physical or mental illness, disability, frailty or substance misuse.

I am a:

Title
(Required.)

First name (Required.)

Surname (Required.)

Your address: (Required.)

Telephone or mobile number (Required.)

Email address:

Scottish Parliamentary Constituency
(Please choose from the list below. If not known, please leave blank and we will complete for you)

How did you find out about the Carers Parliament? Tick all that apply.