CLIENT REGISTRATION

If you would like to know more about services CARE could offer, please complete and submit the following information.

If you are registering on behalf of another person, please complete your name, address and contact details plus the additional information requested.

	Your Name:
	Your Address:
	Postal Code:
	Phone Number:
	E-mail Address:

	If you are registering on behalf of another person please provide their name:-
	Please specify relationship:-

Please indicate in which area, or areas, you would like help:-

Attending Hospital Appointments.

Attending Doctor Appointments.

Attending Other Appointments.
Please specify:-

Shopping.

Other.
Please specify:-

CARE will use the information you have provided above for the sole purpose of letting you know more about the services offered by CARE.
If you, or any other person specified above, subsequently become a client of CARE, we will only use this information, and other information you, or they, may provide us with in the future, for the purpose of providing voluntary services as outlined in this site.
We will not disclose this information to any person outside CARE or any external organisation, except in order to provide said voluntary services or other services as requested.