Caregiver Registration Form
Caregiver Details
Name of Caregiver
Select Option
Mr
Mrs
Ms
Mdm
Dr
Name of RC social worker (if relevant)
Select
AHS Social Workers
Elizabeth Quek
Jaine Cheong
Jasmine Ng
Nadiah Aqilah Binte Bohari
Nuraniah Binte Anguani
Timothy Chua
Venus Ong
Contact Number of Caregiver
Email of Caregiver
Residential Details
Postal Code
Street Name
Unit / House No.
Youth Details
Name of Youth
Is youth a client/ex-client of Rainbow Centre?
Yes
No
DOB of Youth
Gender
Male
Female
Location of Youth
Select
North
South
East
West
Central
North-East
Disability of Youth
Youth Info (e.g. personality, characteristics, preferences)
Preferred Schedule
TIME
MON
TUE
WED
THU
FRI
SAT
SUN
Morning
Afternoon
Evening
I confirm that I have read and agree to Rainbow Centre’s
Privacy Statement
and I consent to the collection, use and disclosure of my personal data by Rainbow Centre for the purpose of the Good Life Befriender programme.
Submit
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