Are you a (please tick button)  Parent ?  Carer? 

 Professional?   Other 

Professional or Other please give details (including numbers of children in care, sight impairment, other disability etc.):

Contact address:

House number and street

Town 

County 

Post Code 

E-mail address? (this is essential if you wish to receive a reply)

Children's names

1st child

AgeMale Female 

Registered Blind/Partially-sighted/Disabled?  Yes   No 

Registered Deaf/Hearing-impaired  Yes   No 

2nd child's name

AgeMale Female 

Registered Blind/Partially-sighted/Disabled?  Yes   No 

Registered Deaf/Hearing-impaired?  Yes   No 

3rd child's name

AgeMale Female 

Registered Blind/Partially-sighted/Disabled?  Yes   No 

Registered Deaf/Hearing-impaired?  Yes   No 

4th child's name

AgeMale Female 

Registered Blind/Partially-sighted  Yes   No 

Registered Deaf/Hearing-impaired  Yes   No 

5th child's name

AgeMale Female 

Registered Blind/Partially-sighted/Disabled?  Yes   No 

Registered Deaf/Hearing-impaired?  Yes   No 

If none of the children are registered, which child has the visual impairment or other disability?

Anything else that you think we should know?

Do you currently receive our newsletter?   Yes   No 

If no, do you wish to receive our newsletter?  Yes   No 

In addition to joining OKE, do you want to join our email support group?  Yes   No 

Do you feel you could contribute anything to the group and be willing to assist in the running of the group?  Yes   No 

Where did you hear about us?