Title: Mr Mrs Miss Ms
First Name:
Last Name:
Address:
Town/City:
Post Code:
Telephone Number:
Mobile Number:
Email Address:
Date Of Birth:
Next Of Kin Name:
Next Of Kin Telephone:
Registration Information: Blind (SSI) Partially Sighted (SI) Not Registered Pending Registration Do Not Wish To Register Not Possible To Register
Sight Condition: Macular Degeneration Diabetic Retinopathy Cataracts Glaucoma
Other Sight Condition:
Second Sight Magazine: Large Print Cassette CD Braille Email
Do You Live Alone? Yes No
Let Us Know If You Have Any Interests:
Do You Wish to Attend One of Our Local Clubs? Yes No
Referral: Self HACB (HACB Branch) Social Service Dept Eye Clinic
Other Referral:
Changes To Our Records. Please Complete Only If a There Is Any Change
Update Database: Deceased Moved Away Remove Record Change Of Address Update Record
Other Changes:
This information is confidential and held securely. It is not passed to third parties without your permission. Where this may be required we will ask for your permission in advance.
I agree to the statement above and for Open Sight (Hampshire Association for the Care of the Blind Ltd) to hold the information given on this form.
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Copyright © 2006 Hampshire Association for the Care of the Blind Ltd. Registered Office, 25 Church Road, Bishopstoke, Eastleigh, Hampshire, SO50 6BL. Charity Number 1055498. Company Registration No. 3178631
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