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Name: |
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| Email Address:
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| Address:
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| Telephone:
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Are you: |
Male?
Female? |
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Are you: |
A carer?
An
ex-carer?
A worker?
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| Do you represent a particular
group or organisation? |
| Yes
No
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| If yes, please indicate which
group. |
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In order to ensure a wide
representation of carers, please indicate the
type of caring responsibilities you
have.
(You may check more than
one) |
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| Other (Please specify) |
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