Care Seeker MakCare Connect – Care Seekers Registration Form Please complete the form below to register and get paired with Carers and Care Providers. 1. Your Contact Information Full Name: Phone Number Email Address Home Address: (or location where care is needed) 2. Who Needs Care? Full Name of Person Needing Care: Relationship to You: (e.g., self, parent, spouse, child) Gender MaleFemale Birth Date Languages Spoken AfarAbkhazianAvestanAfrikaansAkanAmharicAragoneseArabicAssameseAvaricAymaraAzerbaijaniBashkirBelarusianBulgarianBihariBislamaBambaraBengaliTibetanBretonBosnianCatalanChechenChamorroCorsicanCreeCzechChurch SlavicChuvashWelshDanishGermanDivehiDzongkhaEweGreekEnglishEsperantoSpanishEstonianBasquePersianFulahFinnishFijianFaroeseFrenchWestern FrisianIrishScottish GaelicGalicianGuaraniGujaratiManxHausaHebrewHindiHiri MotuCroatianHaitianHungarianArmenianHereroInterlingua (International Auxiliary Language Association)IndonesianInterlingueIgboSichuan YiInupiaqIdoIcelandicItalianInuktitutJapaneseJavaneseKartuliKongoKikuyuKwanyamaKazakhKalaallisutKhmerKannadaKoreanKanuriKashmiriKurdishKomiCornishKirghizLatinLuxembourgishGandaLimburgishLingalaLaoLithuanianLuba-KatangaLatvianMalagasyMarshalleseMaoriMacedonianMalayalamMongolianMarathiMalayMalteseBurmeseNauruNorwegian BokmalNorth NdebeleNepaliNdongaDutchNorwegian NynorskNorwegianSouth NdebeleNavajoChichewaOccitanOjibwaOromoOriyaOssetianPanjabiPaliPolishPashtoPortugueseQuechuaRaeto-RomanceKirundiRomanianRussianKinyarwandaSanskritSardinianSindhiNorthern SamiSangoSinhalaSlovakSlovenianSamoanShonaSomaliAlbanianSerbianSwatiSouthern SothoSundaneseSwedishSwahiliTamilTeluguTajikThaiTigrinyaTurkmenTagalogTswanaTongaTurkishTsongaTatarTwiTahitianUighurUkrainianUrduUzbekVendaVietnameseVolapukWalloonWolofXhosaYiddishYorubaZhuangChineseZulu Any Communication Needs? YesNo If yes, please specify: 3. Type of Care Required (Tick all that apply) Personal Care (e.g., washing, toileting)CompanionshipMeal PreparationLight HousekeepingMedication SupportMobility AssistanceShopping & ErrandsEscort to AppointmentsOvernight/Sleep-in SupportLive-in CareDementia/Alzheimer's CarePalliative/End-of-Life CareRespite or Emergency CoverComplex Care (e.g., PEG feeding, catheter care)Other (please specify): 4. Preferred Carer Requirements Gender Preference: No PreferenceMale Female Language Preference: Do they require a driver? YesNo Any cultural/religious preferences or sensitivities? 5. Schedule & Availability Type of Care: Personal Care (e.g., washing, dressing)Live-In Care Dementia CarePalliative/End-of-Life Care Respite CareCompanionship Complex Care (e.g., PEG feeding, tracheostomy)Learning Disability Support Children’s CareOvernight/Sleep-in Care Domestic Support (cleaning, meal prep)Hospital Discharge/Reablement Other (please specify): ________ Days Required: MonTueWedThrFriSatSun Hours Per Day: Start Date: Is this ongoing or short-term? OngoingTemporary Unsure 6. Medical & Support Needs Does the person have a diagnosis or condition? (e.g., dementia, stroke, autism) Mobility Level: Fully MobileNeeds Some Help Bedbound Is any equipment used? (e.g., hoist, wheelchair): 7. Budget & Payment Hourly Budget (if known): £_ Payment Method: Private PaymentDirect Payments (from local authority) NHS Continuing CareUnsure 8. Additional Notes / Preferences Please provide any other important information about the person, their personality, care routine, or what kind of carer would suit them best. 9. Submit Your Request Policy ☐ I agree to the privacy policy and terms.☐ I understand this form does not confirm care but starts the matching process. Only fill in if you are not human Login
