Emergency Card Registration 1:3
Please complete this form so that Borders Carers Centre can send you your emergency cards. If you need help to complete this form, please: phone us on 01896 752431 or visit us at Brewerybrig, Low Buckholmside, Galashiels TD1 1RT (open 9am to 4pm daily)
Privacy Notice
Please be aware that: we hold the information (data) you have provided on Borders Carers Centre’s secure database we only share this information with council staff who operate the on-call service for emergency cards (information is shared with the NHS, Police and any other relevant services only if a card is activated) you are agreeing to our holding and sharing this information when you sign the various declarations contained in this emergency card registration form
CARER
Name in full
Address incl. postcode
Telephone Landline	Telephone Mobile
GP & Surgery
May we tell your doctor you are a carer?	Date of Birth
CARED FOR
Name in full
Address incl. postcode
Telephone Landline	Telephone Mobile
GP & Surgery
May we tell your doctor you are cared for?	Date of Birth
(Cared for) Relationship to you

CARED FOR continued 2:3
Please tell us about anyone else who lives with the cared for person?
How long can the cared for be left alone? Days / Hours / Minutes
Is there anything about the cared for that you feel we should know? For example, can they be left alone, do they take prescribed medication, are they diabetic, epileptic?
Please tell us about any daily/ weekly services the cared for receives, eg. home care, day centre, school?
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY

Emergency contact primary 3:3
Name in full
Address incl. postcode
Telephone Landline	Telephone Mobile
Relationship to CARER	Relationship to CARED FOR
YES	NO
Is the primary contact a KEYHOLDER?
Is the primary contact over 18 years?
Signature of Primary contact	Date
Emergency contact secondary
Name in full
Address incl. postcode
Telephone Landline	Telephone Mobile
Relationship to CARER	Relationship to CARED FOR
YES	NO
Is the secondary contact a KEYHOLDER?
Is the secondary contact over 18 years?
Signature of Secondary contact	Date
Declaration
Signature	Date
CARER
CARED FOR
Please return this form to: Borders Carers Centre, Brewerybrig, Low Buckholmside, Galashiels TD1 1RT
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