better standard of living
Disability Form
Please fill the form carefully, you will be contacted when necessary.
pls if any field is not applicable to you kindly leave blank or click not applicable
pls if any field is not applicable to you kindly leave blank or click not applicable
pls if any field is not applicable to you kindly leave blank or click not applicable
pls if any field is not applicable to you kindly leave blank or click not applicable
Personal Data
Surname
First Name
Middle Name
Address
Home Town
Local Government of Origin
State
Geopolitical Zone
More information
Occupation
if others please specify here otherwise leave empty
Sex
Marital Status
Email Address
Repeat to confirm
Phone Number
Age
Social Media Links
WhapsApp
others please specify
Type of Disability
Hearing Impairment
others (if others please specify below)
Do you use a sign Language Interpreter
Visually Impaired
others (if others please specify here otherwise leave blank)
Can you read Braille
Can you use smart phone
Mobility Impairedment
Intellectual Disability
others (if others please specify here otherwise leave blank)
Electoral Details
Do you have permanent Voter's Card
Have you registered before
Have you voted before
if you have voted before , how did you vote
is the pooling unit disability friendly
Pooling Unit close to you (leave empty if you don't know)
Which Ward are you from (leave empty if you don't know)
final step
was there availability of Braille and other facilities for the blind and virtually impaired
What Challenge did you encounter and how did you solve it
upload passport (full size for those with mobility impairment)
Max. size: 256.0 MB
Upload medical report if available
Max. size: 256.0 MB