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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.
  • Hidden
    Please only select this box if the person also requires a set of headphones
  • This field is for validation purposes and should be left unchanged.