ONLINE SERVICES
Registration Form - PWD
Republic of the Philippines
Province of Palawan
Municipality of Taytay
DEPARTMENT OF HEALTH
Philippine Registry for Person with Disabilities
Application Form
New Applicant
Renewal
2. Person with Disability Number
3. Date Applied
4. PERSONAL INFORMATION
Surname
Firstname
Middle name
Suffix
5.Date of Birth
6.Sex
Choose...
male
Female
7.Civil Status
Choose...
Single
Seperated
Cohabitation(live-in)
Married
Widow/er
8.Type of Disability:
Deaf or Hard of Hearing
Intellectual Disability
Learning Disability
Mental Disability
Physical Disability(Orthophedic)
Psychosocial Disability
Language and Speech Impairment
Visual Disability
Cancer(RA11215)
Rare Disease(RA10747)
9.Cause of Disability
Congenital/Inborn
Acquired
ADHD
Chronic Illness
Cerebral Palsy
Cerebral Palsy
Down Syndrome
Injury
Others, Specify:
Others,Pls.Specify:
10.Residence Address
Region
Province
Municipality
Barangay
House No. and Street
11.Contact Details
Landline Number
Mobile Number
Email Address
12.Educational Attainment
Choose...
Kindergarten
Elementary
Junior High School
Senior High School
College
Vocational
Post Graduate
Graduate
13.Status of Employment
Choose...
Employed
Unemployed
Self-Employed
13 a.Category of Employment
Choose...
Government
Private
13 b.Types of Employment
Choose...
Permanent/Regular
Seasonal
Casual
Emergency
14.Occupation
Choose...
Managers
Professionals
Technicians and Associate Professional
Clerical and Support Workers
Service and Sales Worker
Skilled Agricultural, Forestry and Fishery Workers
Craft and Related Trade Workers
Plant and Machine Operators and Assembles
Elementary Occupations
Arm Forces Occupations
Others,
Others, Specify
15. Organization Information
Organization Affillated
Contact Person
Office Address
Telephone Number
16. ID Reference No.
(Put N/A if not available)
SSS No.
GSIS No.
Pag-Ibig No.
PSN No.
PHILHealth No.
17. Family Background
Father's Last Name
First Name
Middle Name
Mother's Last Name
First Name
Middle Name
Guardian's Last Name
First Name
Middle Name
18.Accomplished By:
Choose...
Applicant
Guardian
Representative
Last Name
First Name
Middle Name
19.Name of Certifying Physician:
Last Name
First Name
Middle Name
20.Processing Officer:
Last Name
First Name
Middle Name
21.Approving Officer:
Last Name
First Name
Middle Name
22.Encoder Officer:
Last Name
First Name
Middle Name
23.Name of Reporting Unit(Office/Section)
24. Control No.