Registration Form

/Registration Form
Registration Form 2018-11-01T15:50:17-04:00

THIS FORM SHALL BE ANSWERED BY (OR FOR) PEOPLE WITH DISABILITIES.

PLEASE FILL OUT THIS FORM AND SUBMIT TO THE NATIONAL COMMISSION ON DISABILITY.

Personal Information

Your Last Name
Field is required!
Sex
Field is required!
Your First Name
Field is required!
Date of Birth:
Select a date
Field is required!
Age:
Field is required!
Region
  • - select a region -
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
- select a region -
Field is required!
Are you a Guyanese National?
Field is required!
Other Nationality:
If you are not Guyanese what is your nationality
Your Nationality
Field is required!
Lot and Street:
Lot and Street
Field is required!
Town and Village:
Field is required!
Type of Residence:
Field is required!
Home Phone Number:
Field is required!
Mobile Number:
Field is required!
Your Email Address
Field is required!

Disabilities

Source or Cause of Disability and Age Disability was diagnosed.
If you have more than one, add it using the + button after the disability fields.
Disability Type
  • - select a option -
  • Attention deficit and Hyperactivity Disorder (ADHD)
  • Autism
  • Blind
  • Cerebral Palsy
  • Deaf
  • Down Syndrome
  • Hearing Impaired
  • Learning Disability (Dyslexia, understanding)
  • Mental Health Issues
  • Orthopaedic Impairment (difficulty moving, reaching, Kneeling, grouching, gripping, holding objects)
  • Schizophrenia
  • Speech Impairment
  • Tasting, Smelling, or Feeling ( Physical Touch)
  • Visually Impaired (even if wearing glasses)
- select a option -
Field is required!
Cause or Source of Disability
  • - select a option -
  • (1) Born with Disability
  • (2) Acquired disability by disease
  • (3) Violence
  • (4) Acquired disability due to an accident at Work
  • (5) Acquired disability due to a Vehicular accident
  • (6) Acquired disability due to an accident while at Home or at Recreation
  • (7) Not Sure
- select a option -
Field is required!
Age Disability Diagnosed
Field is required!
Other Disability:
List any other disabilities along with the cause/source and age diagnosed
Field is required!

Additional Information

Kindly indicate if you currently attend school
Field is required!
Your age when you first attended school:
Field is required!
Your age when you left school:
Field is required!
What type of school did you attend?
Field is required!
Do you need schooling?
Field is required!
Type of classes needed:
Field is required!
Currently Employed:
Field is required!
Your Profession:
Field is required!
Do you require training to be employed?
Field is required!
Training Required:
Field is required!
What are your sources of material and financial support?
Field is required!
Do you use any assistive aid for your disability?
Field is required!
What assistive aids do you use?
Wheelchair, hearing aid etc.
Field is required!
Do you need any assistive aid for your disability (e.g. wheelchair, hearing aid, walking aid)?
Field is required!
Assistive Aids Needed:
wheelchair, hearing aid, walking aid etc.
Field is required!
Are you a member of any disability organization/s? If so state which:
Organization Name
Field is required!
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