Veda Test

1. About yourself

Name (first)*

Name (last)*

Address

Street AddressAddress Line 2CityPost CodeCountry

Email*

Phone

Gender*

Your year of birth

Your main language

For example, English, Polish, Punjabi. Please leave blank if you do not wish to disclose. We collect this information as it helps to ensure we are inclusive, and we use it in our funding bids which allow the family carer email network to continue.

Your ethnicity

Please pick from the drop down next to which box best describes your background. Please leave blank if you do not wish to disclose. We collect this information as it helps to ensure we are inclusive, and we use it in our funding bids which allow the Family Carer Email Network to continue.

How did you hear about the email network?

I would like to receive a copy of the newsletter by email (e-Challenge)

Yes
No

I would like to receive a hard copy of the newsletter by post (Challenge) when available

Yes
No

I would like to receive more information about Carers' Catch Ups (informal chat groups with other families)

Yes
No

I would like to apply to receive the 'Headspace' app for free

Yes
No

You can get more information about Headspace, the meditation and mindfulness app, at https://www.headspace.com

2. About your family member with challenging behaviour

Name (first)*

Name (last)*

Year of birth

Gender

Relationship to you

What level of Learning Disability does your family member have?

NB this network is only for people whose relative has a severe learning disability

Does your family member have a diagnosed syndrome/condition? (please specify)

E.g. ASD, Down Syndrome, Smith Magenis etc.

What level of communication does your family member have?

Where does your family member live?

Type of challenging behaviour – Please pick any behaviour/s your family member displays

Consent*

By submitting this form you agree that the information is accurate and that you are happy for us to hold this information on file and to contact you again in the future.

The information you share with us will be held on a secure database and used for the purpose of administering the CBF Email Network. We do not share or sell our data to any third party. You can unsubscribe at any time by emailing: network@thecbf.org.uk

We may contact you for further information about your relative to ensure the Email Network will be the best support for you. We can provide a list of other forums on request, as there are other support networks which might be more helpful for you and your relative.

The network is moderated by the Email Network Coordinators at the CBF, who anonymise messages and replies and circulate them to the network. We will send you an email to let you know when your address has been added to the email network. To send a message to the network, email network@thecbf.org.uk

Email

This field is for validation purposes and should be left unchanged.

Testing Gravity Form - Standalone

Application form for Family Carers - Veda Test

1. About yourself

2. About your family member with challenging behaviour