Register as disabled form

Privacy notice – Please read before submitting your information >

When you submit this form you are sending your information to Hertfordshire County Council (as the Data controller). This information is being gathered and will be processed on the basis that you are giving consent for us to do so. If you wish to withdraw consent at any time you can request to have your data deleted by contacting our Data Protection Team - data.protection@hertfordshire.co.uk.

The information you give us will be processed by Serco under contract to Hertfordshire County Council and will only be used to provide the service you are contacting us about.

We will not share this information with a third party or use it for any other purpose.

The contact information that you supply to us will be kept on file for two years. For more information visit our website privacy policy.

Full name
Date of birth (dd/mm/yyyy)
Address
Address line 1
Address line 2
Town
County
Postcode
Contact details
Phone
Email
How would you prefer us to contact you?
EmailPost
Ethnicity
You don't have to tell us your ethnicity. We only ask to make sure we're meeting the needs of all our customers.
Have you seen an occupational therapist or a social worker?
YesNo

When you submit this form you are sending your information to Hertfordshire County Council to register as disabled. We'll only contact your doctor for them to share relevant information with us if you give your consent on this form.

For more information you can see our website privacy policy.

Register as disabled form

You don't have to tell us your ethnicity. We only ask to make sure we're meeting the needs of all our customers.

Only fill in this page if you're completing the form for someone else. Otherwise, skip to the next page.

Rate this page