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Surrey Disability Register Registration Form

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Please complete all fields marked *. Hover your mouse over anyExample of help marks for additional help.
Where did you hear about the Surrey Disability Register? *
Section 1 Your disability or impairment
The Equality Act 2010 defines a disabled person as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. ‚€˜Long term‚€™ means that the effect of the impairment has lasted or is likely to last for at least 12 months (there are special rules covering recurring or fluctuating conditions). ‚€˜Normal day-to-day activities‚€™ include everyday things like eating, washing, walking and going shopping. The progressive conditions of HIV, cancer and multiple sclerosis are covered from the point of diagnosis, rather than from the point when the condition has some adverse effect on their ability to carry out normal day-to-day activities.
Please indicate below the impairment or disability you have *
Section 2 Key personal details
What gender do you most identify with *
Are you *
Do you live alone?
Section 3 How you communicate
Please tick the box which best describes how you prefer to communicate: *
What is your preferred format to receive information
Would you like to talk to someone about
Patient Passport
Intended to help staff from health care services to offer you the right help at the point of contact with services. Search for Patient Passport on or call 0300 200 1005 or text 07527 182861
Deafness, hearing loss and sight loss
Sensory Services by Sight for Surrey is the largest charitable organisation in Surrey working with people who are visually impaired, Deaf, Hard of Hearing or who have combined sight and hearing loss, Deaf and Hard of Hearing. The charity has provided support to the blind and partially sighted community since 1922. It began to deliver services to the Deaf and Hard of Hearing in February 2016 after securing a contract by Surrey County Council to provide these services. Their mission is to help anyone whose eyesight or hearing has become a cause for concern, whether they are registered with a sight impairment or not, to help them lead full and independent lives. To achieve this they provide a wide range of service to vision impaired people and their carers, including amongst others Communicator Guides who support anyone with a combined sight and hearing loss, specialist Hearing Loss Advisors, Volunteer befrienders and specialist technology training at all levels. All of their staff have a real understanding of the practical and emotional aspects of living with hearing and sight loss.
If you want to receive information from Sensory Services by Sight for Surrey, please tick this box
Becoming involved
Surrey Coalition of Disabled People is an independent organisation funded by Surrey County Council to be the central point for engagement with disabled people, so that they can influence how service are delivered and could be improved. Would you like information from them on how to become involved in their activities?
Please also tick which group, if any, you would like to be involved in
Section 5 Equality and diversity - These questions are optional - you do not have to respond to them if you would prefer not to
The information collected here is for the purpose of equalities monitoring in the provision of care service and to meet legal requirements that Surrey County Council must keep to show that they do not discriminate against people because of their personal or cultural differences. We don't want anybody to miss out or be disadvantaged because of the way we work, and we work hard to make sure that this does not happen. One way for us to know how we are doing is to find out about who is using our services. You can help us to make sure we provide services equally and fairly by answering a few simple questions about yourself. This will take no more than a couple of minutes. Whatever you say is completely anonymous and confidential and will not be linked back to you. We will look closely at this information to see if there are groups of people that are not getting the best from us. If we see this is the case what you tell us will help us improve things.
Which of these groups do you belong to?
Black or Black British
Asian or Asian British
Other backgrounds
I prefer not to say
Which of the following faith and belief groups do you identify with?
This includes a religous belief or a philosophical belief, which affects your view of the world. It also includes people who have no religion or belief.
Which of these best reflects your sexual orientation?
I am
There may be times when we need to share your information with different agencies to ensure that you receive the most appropriate and timely services; for instance professionals in the local borough and district housing departments and the NHS. The information will be shared securely and only for your benefit to ensure continuity of support.
Please tick below
Who is the person submitting this form?
What happens next?
Thank you for submitting this form. The information in this form will be entered onto a computer database. Your registration card and pack will then be sent to you. If you have supplied an email address, we will use it to communicate with you.
If you have completed all the fields marked *, then please click "Submit".