Your Full Name (required)

Your Email (required)

Telephone

Your Home Address (required)

What type of Shared Lives carer do you want to be? (required)
Long term/permanent placementsShort term breaks

Which group of people do you want to support? (required)
People with a learning disabilityOlder adultsPeople with physical disabilitiesPeople with mental health issues

Any other details you would like to tell us (optional)

Where did you hear about Shared Lives? (required)
Recommended by a shared lives carerPossAbilities job vacanciesPossAbilities Facebook or TwitterPossAbilities websiteWord of mouthOther

The information you have provided above will be held on our database and will be used to assess your suitability as a carer, it will also be used for statistical purposes. Please tick here if you provide consent for this information to be held and used as stated. (required)
I agree