Caregiver ID Application Form Title: (Ms., Mr., Mrs., Dr.)* First Name* Last Name* Street Number and Name* City* Province* Postal Code* Telephone Number* Email* I provide unpaid care for someone who needs help due to disability or ill health. This includes caring for a family member, loved one or friend without receiving pay.* Yes No I care for multiple people.* Yes No On average how many hours per week do you provide care*. I consent to my personal information being collected and shared to better support me as a Caregiver (i.e., to refer to other organizations to provide resources / support).* Yes No How did you hear about Caregiver ID? Submit Application NOTE: Please email a photograph of yourself to [email protected] so we can create your badge. If you are having difficulties with this please contact the issuing agency. File should be labeled FirstName-LastName.jpg Minimum resolution 200 X 230.