Family Carers Ireland

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

Email Address*

*Check if email is already registered*

Title

Gender*

First Name*

Surname*

Date Of Birth*

EirCode* Find your EirCode

Address Line 1*

Address Line 2*

City/Town

County*

Mobile Number*

Landline Prefix

Landline Number

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*

Advocacy & Campaigning

Carer Groups

Fund Raising

Research

Support

Services

Training

Volunteering

Events

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

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: *

Member Application