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AN NGO FOR THE PEOPLE WITH SPINAL CORD INJURY, AND MULTIPLE DISABILITIES . REG NO 35/2014 , AN 80 G CERTIFIED. HELP LINE NUMBER: 0 96771 89009
Registration - Beneficiary
Name
*
Age
*
Gender
*
Male
Female
3rd Gender
Date of Birth
*
Email
*
Mobile
*
Type of injury
*
Year of Injury
*
Address
Medical Summery
City
*
Piocode
*
REHABLITATION DETAILS
*
Yes
No
If yes, Where
*
When
*
Application For (You can choose multiple)
*
CALLIPERS
LEGS
LIMBS
HEARING AID
CANE
WALKERS
WHEELCHAIR
COMMODE CHAIR
TRICYCLE
STOOLS STIMULATOR CANE
CATHETERS
URINE BAGS
If CALLIPERS Chosse Right or Left
*
Right
Left
Both
If LEGS Chosse Right or Left
*
Right
Left
Both
If LIMBS Chosse Right or Left
*
Right
Left
Both
If HEARING AID Chosse Right or Left
*
Right
Left
Both
If CANE AID Chosse Right or Left
*
Right
Left
Both
If WALKERS AID Chosse Right or Left
*
Right
Left
Both
If you choose WHEELCHAIR/ COMMODE CHAIR/ TRICYCLE
Size
*
Type
*
Details
If you choose STOOL STIMULATOR/ CATHETERS / URINE BAG
Size
*
Type
*
Details
2% HYDROCHLORIDE JELLY
*
YES
NO
Proof of Identity
Proofs
*
Choose One
DISABILITY CARD
VOTER ID
AADHAR CARD
Proof ID Number
*
Scanned copy of your photo(jpg,jpeg,png)
Reference
Reference Name
*
Reference Mobile
*
