Disabled Persons’ Accommodation Agency -Registration Form

 Applicant’s details             The applicant does not necessarily need to be the person with a physical
disability or sensory impairment - it should be the person to be contacted on any matters concerning the
information given on this form or if a possible property becomes available.

Present address:_____________________________________________________

 __________________________________________ Postcode: _____________

 Telephone: ___________________________ Minicom:________________________

Members of Household                Please detail everyone who needs housing including a carer if you are expecting to have one. Please add a continuation sheet if necessary:

Current Housing

Tick if you are:                                                          

Physical Impairment

Please tick if

 If you are a wheelchair user, tick if you use it: 

Sensory impairment  (Please tick)

The DPAA will use this information to classify your accommodation need . if you wish to give us any
other information about your needs, please include it here:

Location

Where would you like to live? Please tick the district council areas that you would like to live in.
Tick as many as necessary:

 Code        District                                             ü      Code         District                                              ü

Other (Please specify)_____________________________________ 

If you wish, name the towns, areas or districts within these areas that you would like to live in.
You can be as general or specific as you want to be, but bear in mind that the smaller the area,
the more difficult it will be for us to find appropriate accommodation for you:

 Requirements 

 (Consider the need to accommodate a carer, if required. Remember that councils and housing associations have rules about under occupation and may not be willing to offer you accommodation with a spare room.) 

 Tick if you want  

Tick if you have  

 Tick if you would consider 

  Tick if you want to  

If you want to buy, what is the highest price that you would be prepared to pay?   £ 

Any other information     Please give any other information which you would like
us to consider in assessing your housing need

 For our records    The information in this section is only used to help us to monitor the fairness
and effectiveness of our service. 

Where did you find out about the DPAA ? 

What is your ethnic origin?  

Terms and conditions

1.                  Any properties suggested to you through this scheme will not have been Inspected by the Disabled Persons Accommodation Agency.  Their inclusion on any lists produced by the Disabled Persons Accommodation Agency dose not mean the premises are recommended by the Agency, or that they are safe or fit for occupation.  You must ensure yourself that the premises are safe and fit for occupation.

2.                  The Disabled Persons Accommodation Agency will not be responsible for any loss you suffer as a result of your  property, or goods being destroyed, damaged, or stolen, whilst you are living at one of the properties that you were made aware of by the Agency will be able to find you a new home, but it will improve your chance.

3.                  Informing the Disabled Person Agency Accommodation Agency of your housing requirements will not guarantee that the Agency will be able to find you a new home, but it will improve your chances,

4.                  The information supplied on the applied on the application form may be passed on to other organisations that are working with the Disabled Persons Accommodation Agency and who may have a property that could be suitable to the applicant’s needs.