Apply for the carer's emergency card

Your details
Full name*

First nameLast name
Home telephone
Work telephone
Mobile telephone
Email address*
Address*
Postcode*
Your date of birth*

DayMonthYear
Details of the person you care for
Full name*

First nameLast name
Date of birth

DayMonthYear
Address*
Postcode*
Home telephone
Work telephone
Mobile telephone
GP name*
GP Practice*
GP telephone*
What is the relationship to you of the person being cared for?*
What is his/her illness or disability?*
Please list all conditions, such as "diabetes - tablet controlled / dementia / deaf or hard of hearing etc
Nominated people
Is there a friend or relative who could take your place at short notice?*

YesNo
If yes, they must have access to the property and be able to fill in or know what to do in an emergency. A basic 'Plan of Care' is available for the carer and nominated person(s) to fill in and keep handy.
Would you like to be sent the plan of care?

YesNo
Number of copies
Nominated person 1 - First contact
Person 1 name

First nameLast name
Person 1 address
Person 1 postcode
Person 1 home telephone
Person 1 work telephone
Person 1 mobile telephone
Person 1 email address
Person 1's relationship to the person being cared for
Nominated person 2 - Second contact
Person 2 name

First nameLast name
Person 2 address
Person 2 postcode
Person 2 home telephone
Person 2 work telephone
Person 2 mobile telephone
Person 2 email address
Person 2's relationship to the person being cared for
What if there is no nominated user?

If there is no nominated person or the nominated person(s) are not available, we will automatically call Social Services to make emergency arrangements.
Is the person you care for known to Social Services?

YesNo
Which worker/team?
Information to share with the emergency services

What does the person you care for need help with? (Please select all the relevant options)
Walking / getting around in a wheelchair

YesNo
Washing / dressing

YesNo
Keeping an eye on (maybe confused or prone to agitation)

YesNo
Preparing food and drinks

YesNo
Taking tablets or other medicines

YesNo
Something else?

YesNo
Please tell us more including dietary, cultural or religious needs
Emergency services
How would the emergency services get in? Is there a spare key? Please describe who has it and how to get hold of them/where it's kept or how it can be accessed.
Other support
Please tell us about any services already in place e.g. home/daycare
Name of person or service
What they do
When they visit/services take place
Contact number
If more than one service is received please give us full details of the others
Other information
Please tell us anything else that may be useful for people to be told, including whether there is a pet and what you want us to do with it
Completed by
Full name*

First nameLast name
Telephone number*
Email address*
Should be Empty:

Your details

Details of the person you care for

Nominated people

Nominated person 1 - First contact

Nominated person 2 - Second contact

What if there is no nominated user?

Information to share with the emergency services

Other support

Other information

Completed by