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Title: |
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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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What is your age? |
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Are you: |
an unpaid Carer?
past Carer?
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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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What age
is the person you care for?
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Under 18 years |
| 18 - 65 |
| 65+ |
Does the person you care for have?
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| Other (please specify) |
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