Philippine Registry for Persons with Disabilities

DEPARTMENT OF HEALTH

Philippine Registry for Persons with Disabilities Version 4.0

Application Form

1. APPLICATION TYPE

New Applicant

Renewal

2. PERSON WITH DISABILITY NUMBER Disability Number must be exactly 19 characters in the format RR-PPMM-BBB-NNNNNNN.

3. DATE APPLIED

4. PERSONAL INFORMATION

Last Name

First Name

Middle Name

Suffix

5. DATE OF BIRTH

6. Sex

Female

Male

7. CIVIL STATUS

Single

Separated

Cohabitation (live-in)

Married

Widow/er

8. TYPE OF DISABILITY

Deaf or Hard of Hearing

Intellectual Disability

Learning Disability

Mental Disability

Physical Disability (Orthopedic)

Psychosocial Disability

Speech and Language Impairment

Visual Disability

Cancer (RA11215)

Rare Disease (RA10747)

Please select at least one disability.

9. CAUSE OF DISABILITY

Congenital/Inborn

Autism

ADHD

Cerebral Palsy

Down Syndrome

Acquired

Chronic Illness

Injury

Please select at least one cause of disability.

10. RESIDENCE ADDRESS

11. CONTACT DETAILS

+63

Please enter a valid contact number (must start with 9 and have 10 digits).

Please use a valid Email.

12. EDUCATIONAL ATTAINMENT

None

Kindergarten

Elementary

Junior High School

Senior High School

College

Vocational

Post Graduate

Others, specify:

Please select your educational attainment.

13. STATUS OF EMPLOYMENT

Employed

Unemployed

Self-employed

Please select your employment status.

13 a.Category of Employment

Government

Private

None

Please select your employment category.

13 b.Type of Employment

Permanent/Regular

Seasonal

None

Please select your type of employment.

14. OCCUPATION

Managers

Professionals

Technician and Associate Professionals

Clerical Support Workers

Sevice and Sales Worker

Skilled Agricultural, Forestry and Fishery Workers

Craft and Related Trade Workers

Plant and Machine Operators and Assemblers

Elementary Occupation

Armed Forces Occupations

Others, specify:

Please select your type of occupation.

15. ORGANIZATION INFORMATION

16. ID REFERENCE NO

17. FAMILY BACKGROUND

FATHER'S NAME

MOTHER'S NAME

GURDIANS

18. ACCOMPLISHED BY:

APPLICANT

GUARDIAN

REPRESENTATIVE

Please select who accomplished the form.

Last Name

First Name

Middle Name

19. NAME OF CERTIFYING PHYSICIAN/LICENSE NO:

This form, provided by the Local Government Unit of Santa Rosa, supports individuals applying for PWD registration. Data Privacy Notice Your information is protected under the Philippine Data Privacy Act (RA 10173) and will only be used to process your application and assess benefits eligibility. We ensure your data is secure, confidential, and handled exclusively by authorized personnel within Santa Rosa LGU. Thank you for trusting us to keep your information safe.