Register your disability details

Your details

First name

Last name

Mobile number

Email address

Disability details

Tell us about your disability (tick all that apply)

Visual

Hearing

Mobility

Speech

Learning

Mental health

I no longer have a disability

Are you reliant on your mobile?

Yes: I'm registered as Chronically Sick and Disabled (incapacitated and therefore housebound, due to long-term illness or disability which prevents me leaving the house without the assistance of another person)

Account details

Account number (if known)

Name on account (if different from above)

First and third digits of the account password

Contact details

If we need to contact you about this form, what's the best way to reach you? (Tick all that apply)

Email me

Call me

Text me

Call someone else

If you selected Call someone else, please fill in their details:

Contact person name (first and last)

Contact person phone number

When you send us your details, we’ll send you an email to confirm that we’ve received them. Your details will be treated in the strictest confidence.