Appl icat ion for Registrat ion Card for People with Disabi l i t ies

Note: Provision of personal data in this form is entirely voluntary. Your application may not be considered if you fail

to provide the personal data required. Personal Particulars ( ) Name (English) ( )

@( )

Recent colour

passport photo@(Please do not

fold)

Surname first

/ / (Enter the same name as appears on your Hong Kong Identity Card / Birth Certificate / other document(s) of identity shown below)

/ / * Hong Kong Identity Card / Passport / Birth Certificate* No. (Please provide a copy of the relevant document of identity)

( )

Other document(s) of identity (Please specify)

Day Month Year Sex Male Female Date of Birth Address ()(Please enter in block letters) Flat/Room Floor Block

Building Road/Street No., Road/ Street/ Housing Estate /

District/Area HK KLN NT

Correspondence Address(If different from the address given above)

HK KLN NT Official use only

Tel. No. Fax. No. PE TM (EDate: )

Type(s) of Disability

( IV( a )) (Please attach documentary evidence for each reported disability. Please refer to Section IV (a) of the Guidance Notes regarding the requirement of the documentary evidence on disability. May select two or more boxes, if applicable.)

1. Hearing impairment > 70 Hearing loss> 70dB 41-70 Hearing loss 41-70dB

26-40 Hearing loss 26-40dB

2. Visual impairment Severe low vision to totally blind Moderate low vision

Mild low vision

3. Physical disability Severe Moderate Mild

4. Speech impairment

5. Intellectual disability Profound Severe Moderate Mild

6. Mental illness

Psychosis Neurosis Other mental disorders

7. Autism

8. / Visceral disability/Chronic illness

Please specify:

9. / Attention Deficit/Hyperactivity Disorder

10. Specific Learning Difficulties

@ IV(a) Please see Section IV(a) of the Guidance Notes for photograph requirement. C R R 3 ( R ev . 1 / 2 0 1 5 ) Please turn overleaf

No.: Official Use Only

# I wish to app ly fo r a new / renewal / replacement# i s sue of the Regis t ra t ion Card for People wi th Disabi l i t i e s and author i se the Cent ra l Regi s t ry for Rehabi l i t a t ion to use my persona l da ta inc luding type(s) o f d i sabi l i ty for the purpose of i ssu ing the Regis t ra t ion Card , and o the r purposes and funct ions as spec i f i ed in the Guidance Notes on Appl ica t ion for the Regis t ra t ion Card for People wi th Disab i l i t i e s .

Signature : Date :

() * Name (Block letters):

* Mr / Miss / Ms / Mrs

HK ID Card No.: ( ) Tel. No.:

()

Please complete this column if you are the parent or legal guardian of the applicant and apply on behalf of the applicant.

#

I , on beha l f o f (appl icant s name) , HK ID Card No. ( ) wish to apply fo r a new / renewal / r ep lacement# i s sue of the Regis t ra t ion Card for People wi th Disabi l i t i e s , and have sought the consent o f the app l ican t to au thor i se the Cent ra l Regis t ry fo r Rehabi l i t a t ion to use h i s /he r pe rsonal da ta inc luding type(s ) of d i sabi l i ty for the purpose of i ssu ing the Regis t ra t ion Card , and o the r purposes and func t ions as spec i f ied in the Guidance Notes on Appl ica t ion for the Regis t ra t ion Card for People wi th Disabi l i t i e s .

Signature :

Date :

* Mr /Miss /Ms /Mrs * / / / Name (Block letters) :

HK ID Card No. : ( ) Tel. No. :

Relationship with applicant (parent or legal guardian ) :

Name of Agency (if applicable) :

* Delete where appropriate IV(c)Please refer to Section IV(c) of the Guidance Notes for details of replacement.

Access to Personal Data 18 22

: You have a r ight to reques t access to and cor rec t ion of your pe rsonal da ta a s provided for in sec t ions 18 and 22 and Pr inc ip le 6 of Schedule 1 o f the Persona l Data (Pr ivacy) Ord inance . Your r ight o f access inc ludes the r igh t to ob ta in a copy of your pe rsona l da ta kep t in the Cent ra l Regi s t ry for Rehabi l i t a t ion subjec t to payment of a fee . Enqui r ie s on the management of pe rsona l da ta , inc luding making of access and cor rec t ion to your pe rsona l da ta , should be addressed to :

Central Registry for Rehabilitation 11 Labour and Welfare Bureau 11/F, West Wing, Central Government Offices, 2 Tim Mei Avenue, Tamar, Hong Kong : 2810 3859 / 2810 3861 Tel.: 2810 3859 / 2810 3861 : 2543 0486 Fax: 2543 0486

Officer-in-charge, Central Registry for Rehabilitation, (please submit this original copy),

CRR4 Certification of Disability Type for Registration Card for People with Disabilities

Name

Sex

M

F

Document of Identity and No.

II This is to certify that the above-named person does not meet the eligibility criteria as set out in Section II of the Guidance Notes on Application for the Registration Card for People with Disabilities.

II This is to certify that the above-named person meets the eligibility criteria as set out in Section II of the Guidance Notes on Application for the Registration Card for People with Disabilities. The above-named person suffers from the following type(s) of disability: May select two or more boxes, if applicable.

1. Hearing impairment

> 70 Hearing loss> 70dB

41-70 Hearing loss 41-70dB

26-40 Hearing loss 26-40dB

2. Visual impairment

Severe low vision to totally blind

Moderate low vision

Mild low vision

3. Physical disability

Severe

Moderate

Mild

4. Speech impairment

5. Intellectual disability

Profound

Severe

Moderate

Mild

6. Mental illness

Psychosis

Neurosis

Other mental disorders

7. Autism

8. / Visceral disability/ Chronic illness

Please specify:

9. /Attention Deficit/ Hyperactivity Disorder

10. Specific Learning Difficulties

According to the assessment conducted on (date) , the disabling condition is likely to last for:

12 less than or equal to 12 months

12 24 more than 12 months but less than or equal to 24 months

24 more than 24 months

Signature of Doctor

Name of Doctor (Block Letter)

*Signature of Allied Health Professional / Office-in-charge*

*Name of Allied Health Professional / Office-in-charge* (Block Letter)

Please specify field

* Organisation / Hospital* Chop (is required)

*Name of Organisation / Hospital

Date

Tel. No.

CRR4 (Rev. 1/2015) * Delete where appropriate

I.

(/ 11 18)()

IV(a)

II.

III.

IV. a (CRR3) 1 2

11

1

1.

1

2.

CRR4 3.

CRR4 4. 5. (

100%CRR/SWD1

VII

2

(http://www.lwb.gov.hk)

b

IV(a)

11 18 11 18 #

(# IV(a) 2 )

2

[ 3

()

(i)

(ii)

]

c (CRR3)

V.

53

VI.

3

()

VII.

2810 38592810 38613655 4777 2810 3841

4

Guidance Notes on Application for the

Registration Card for People with Disabilities

I. INTRODUCTION The Registration Card for People with Disabilities (the Card) is issued to persons

who have been found to have suffered from a disability(ies) which is permanent in nature, or of a temporary nature. The purpose of the Card is to enable the cardholder to produce, when necessary, as a documentary proof of his/her disability status. It is NOT a privilege card or a credit card.

Since July 2005, a new card bearing the photograph of the cardholder and an expiry

date has been introduced (applicable only to cardholders whose disability is temporary in nature and/or children/juveniles below the age of 11 & 18 respectively). The Cards issued prior to this date are invalid. For renewal, please refer to the application procedure in Section IV(a) below.

II. WHO CAN APPLY

Any person who has been found to suffer from a disability, including Hearing Impairment, Visual Impairment, Speech Impairment, Physical Disability, Autism, Mental Illness, Intellectual Disability, Visceral Disability/Chronic Illness, Attention Deficit/ Hyperactivity Disorder, and Specific Learning Difficulties, and the severity of the disability affects ones major life activities, participation in economic and social activities, and/or mobility, and which takes significantly longer than normal to rehabilitate, may apply for the Card.