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Please complete the form below and a member of the BWBF team will then get in touch with the recipient to arrange a BWBF CONNECT delivery.

BWBF Connect Referral Form

  • SECTION 1 - REFERRER DETAILS

    Please complete Section 1 of the form with the details of the person making the referral.
  • Name of person making this referral
  • Landline or Mobile number
  • Email Address

  • SECTION 2 - RECIPIENT DETAILS

    Please complete Section 2 with the details of the person who the equipment is for.
  • Name of person you would like to receive equipment
  • DD slash MM slash YYYY
  • A contact number is required (can be any number being used on behalf of the recipient, including mobiles)
  • If unknown leave blank
  • DD slash MM slash YYYY
    If unknown leave blank
    Resident in the UK, Registered or registerable blind or partially sighted, Over the age of eight, Receives Personal Independent (PIP) / Attendance Allowance (AA) or Adult Disability Payment (ADP) in Scotland or receives a income related benefit.
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    Please only select this box if the person also requires a set of headphones
    I understand that this set is on loan to me, but will remain the property of the British Wireless for the Blind Fund and is therefore returnable on demand to the Local Agency indicated below (as Agents for BWBF), or to BWBF Head Office as above. I must also return the set to them if I cease to be eligible. I hereby undertake not to part with, sell, or interfere with the item in any way and I will ensure accidental damage insurance is obtained. If the set is accidentally damaged, or will not work, I undertake to notify the below mentioned Local Agency immediately.
    It’s important to us that you feel informed about our news, future developments and fundraising. We want to share with you how your amazing support helps to change the lives of visually impaired people across the UK. Occasionally we will follow up with you to ensure our service continues to meet your needs If you do not wish to be contacted, or you would like to change how we contact you, let us know at any time using the following details – mydata@blind.org.uk, 01622 754757, 10 Albion Place, Maidstone, Kent, ME14 5DZ We respect your privacy and remain committed to ethical and responsible fundraising and communications. Your details will be stored securely and we will never sell them. However, from time to time we may need to share your details with trusted partners authorised to work on our behalf such as our printers or agents (e.g. your local blind association) For further information please refer to our privacy policy – www.blind.org.uk/privacy-policy/
  • This field is for validation purposes and should be left unchanged.