Self Registration Carer - communication

Registration Form

First Name

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Last Name

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Phone Number

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Postcode

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Occupation

Not working right now

Retired

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Age

65 or under 65

65+

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Gender

Male

Female

Non-binary/other

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How long have you been in a carer role

less than 1 year

2-5 years

more than 5 years

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The person you care for had:

a stroke

a brain injury

other

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The person you care for is:

spouse/partner

parent

other family

friend

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Preferred Notification Method

Send me
emails

Send me text
messages

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Email Address

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@

.

.com

.com.au

Password

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