Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697646681135.pdf (Bahamas)
THE NATIONAL COMMISSION FOR PERSONS WITH DISABILITIES The Ministry of Social Services and Urban Development Aventura Plaza, JFK & Bethel Avenue P.O.

Box N-3206 Email: disabilitiescommission@bahamas.gov.bs Website: www.disabilitiescommissionbahamas.org Tel: 242-397-8600/8614 or 24hr Hotline (call or whats app)Tel:242-376-8328 NCPD1 REGISTRATION FORM Date: _____/_____/_____ D M Y A.

Person Completing This Form Are you completing this form on behalf of another person?
Yes No If yes, please provide your name and relationship to the person you are registering: Name: _____________________________________ Relationship: ______________________________ Telephone Contact:____________________________ Email address: ______________________________ B.
Personal Information (Of person with disability being registered) Name: _________________________________________________________________________________ Last First Middle/Other Sex: Male Female National Insurance Number #: __________________________ Date of Birth: _____/_____/_____ Nationality: ______________ Place of Birth: _________________ D M Y Marital Status: Single Married Divorced Widowed Separated Street Address (including house number): _____________________________________________________ P. O.
Box: _________________ Subdivision/Community/Settlement: _____________________________ Island: ______________________ Other: ____________________________________________________ Telephone Numbers: Cell: _________________ Home: __________________Work: _________________ Email address:___________________________________________________________________________ How do you prefer to be contacted (landline/cell/email/SMS text): ________________________________ Contact(s) in case of emergency (name, relationship, contact number): _____________________________ _______________________________________________________________________________________ Will you need to be relocated to an accessible emergency shelter during a pending natural disaster (e.g.
hurricane, flood)?

: Yes Do you require constant medical attention?

Yes If yes, please give details:________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Do you have a Service Animal?
Yes If yes, please give details:_________________________ _______________________________________________________________________________________ C. Information on Disability Type of Disability (Please Check ( ) all that apply): Sight (totally blind or legally blind) Hearing (partially or totally deaf, use of hearing aids) Speech/Communication Autism Mobility/Moving (due to localized, paraplegic, quadriplegic paralysis) Chronic Pain Disorder (that has been medically diagnosed) Mental Disorders Learning/Intellectual/Developmental Disorder Mobility/Moving (due to absent or impaired limb) Other_________________________________(Specify) Please give details about your disability: ______________________________________________________ _______________________________________________________________________________________ Are you presently receiving therapy?
Yes No Locally Internationally Type of therapy being received?
E. Information on Education Check ( ) all that apply: I attended pre-school grade school home school special school alternative school I attend pre-school grade school home school special school alternative school Name of school: _____________________________________________________________ I have completed/finished School graduated from School never attended School Check the highest school grade completed: Check tertiary education completed: Trade/Vocational School College University Other: _F._ Information on Employment Are you currently employed?
Yes If yes, what is your occupation?

_____________________________________________________________ If you are not employed, are you seeking employment?

Yes What are your job preferences?

_____________________________________________________________ What are your skills, training or certification?

__________________________________________________ G. Your Concerns As a person with a disability, or a parent, guardian or caregiver of a person with a disability, what are your top two concerns?
Check ( ) two: Transportation Housing ealth Care Insurance Accessibility Communication/IT Employment Opportunities Educational Opportunities Recreation/leisure/social opportunities Other _____________________________ Please provide additional comments regarding your concerns: ___________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Disclosure of Information I understand that the information I have voluntarily disclosed on this form will be kept confidential.
Relevant information may be shared with other government agencies only as it relates to those agencies’ business with persons with disabilities or connected purposes.

The information provided will be used to inform public policy in order to provide services and disability-inclusive development or to fulfill legal obligation.

__________________________________ Signed: _________________________ Date: THE NATIONAL COMMISSION FOR PERSONS WITH DISABILITIES John F. Kennedy Dr. & Bethel Ave., P.O.
Box N-3206, Nassau, N.P., The Bahamas Phone: (242)-397-8600 Fax: (242)-325-1920 email: disabilitiescommission@bahamas.gov.bs