Sign Up | Family Carers

The below information is necessary so we have the right information about you for our membership database, ensuring all details on the membership card are correct and we can contact you without delay.

Fields marked with an * are required.

I am joining for the first time

I am renewing my membership

Title

Gender

First Name*

Surname*

Date Of Birth*

EirCode* Find your EirCode

Address Line 1*

Address Line 2*

Address Line 3

County*

Email Address* (Please ensure when inputting your email address that there are no blank spaces before or after the address.)

Contact Number (please ensure there are no spaces in your number, e.g. 087XXXXXXX)*

About Your Interests

It is important as a charity that we learn more about your interests and requirements. This means we can always make improvements to our supports and services, based on what you, the family carer wants and needs.

Select your areas of specific interest (you can choose more than one by holding ctrl)*:

Along with the above areas of interest, we will provide you with our quarterly Take Care Newsletter and contact you in relation to our annual AGM and National Conventions.

Please tell us how you heard about us*:

I am a: *

What is your preferred means of contact*:

Please note as a charity, it is more economical for us to connect with you via email or text, so please keep this in mind when selecting the below. It is also more environmentally friendly. We also promise not to flood you with communications and will only be in touch about items of interest.

About the person(s) you are caring for:

YOU MUST COMPLETE THIS SECTION.

Please note, where the cared-for person has the capacity to provide consent, please ensure they have agreed to the disclosure of their contact details and information.

Please provide the full name(s) of the person(s) you caring for:

* Please note this form can reference up to 3 cared for persons only. If you need another cared for person added to the card, please email membership@familycarers.ie immediately after your application.

Cared For Person One Details

Cared For Full Name:

Primary Condition/Illness of Cared For Person:

Secondary Condition/Illness of Cared For Person:

If the cared for person has more conditions/illnesses you would like to list, please tell us here:

Cared For Person Two Details

Cared For Full Name:

Primary Condition/Illness of Cared For Person:

Secondary Condition/Illness of Cared For Person:

If the cared for person has more conditions/illnesses you would like to list, please tell us here:

Cared For Person Three Details

Cared For Full Name:

Primary Condition/Illness of Cared For Person:

Secondary Condition/Illness of Cared For Person:

If the cared for person has more conditions/illnesses you would like to list, please tell us here:

How many hours do you spend caring per week (on average):

The cared for person does not have the capacity to consent, therefore I consent on their behalf: *

The cared for person has given me their permission to list their details as attached: *

In Case of Emergency Details:

YOU MUST COMPLETE THIS SECTION.

In the event of MY accident/illness, please contact the number below as I care for someone, who in my absence may need assistance: Please note this is someone alternative to you.

Emergency Contact Fullname:

Emergency Contact Contact Number:

Please take the time to review all the information you have provided is correct and then click here to confirm:

Member Application

About Your Interests

About the person(s) you are caring for:

YOU MUST COMPLETE THIS SECTION.

Cared For Person One Details

Cared For Person Two Details

Cared For Person Three Details

In Case of Emergency Details:

YOU MUST COMPLETE THIS SECTION.

Get In Touch

Membership