Apply for an audio device

Fill-in this form to apply for an audio device for yourself or someone you support. For full details of our audio devices, user instructions and information on who can apply, visit our audio devices page.

Need help completing our application form? Please call 01622 754757 or email info@blind.org.uk.

Referrer details

* indicates a required field.

Please enter the details of the person who is making the referral

First name*

Last name*

Relationship to person requesting the device *

Please note that some devices are only available via referral from sight loss or support professionals.

Other relationship*

Please describe your relationship with the person you are referring.

Please state your profession*

If you are referring on behalf of an organisation, please state the organisation name.*

Phone number*

Email address*

British Wireless for the Blind Fund (BWBF) would like to keep you informed of our future services, events and fundraising activities.

I am happy to be contacted by BWBF.

Personal details

* indicates a required field.

Please enter details of the person who’ll receive the device

First name *

Last name *

Date of birth *

Phone number *

Email address *

If no email address is available, please add a relevant friend, relative, sight or support professional's email address.

Address

Postcode *

Or enter address manually

Address line 1 *

Address line 2

Town/City *

County

Postcode *

Where should this device be delivered?^*

---------

To this address

To a different address (please provide details)

Eligibility confirmation

To get one of our devices, you need to be:

a resident in the UK
living with sight loss.

You also need to be receiving one of the following benefits:

Disability Living Allowance (DLA)
Personal Independent (PIP) or Attendance Allowance (AA)
Adult Disability Payment (ADP)
any means-tested benefit
a parent or guardian receiving one of these benefits (if the person receiving the device is under 18).

I confirm that the person receiving the device is eligible.*

Sight loss registration^*

Please confirm your sight loss registration

Select an audio device^*

If you are unsure if you are eligible or are not sure which device is right for you, please visit our audio devices page (this link will open in a new tab so that you can come back to this form). You will find details about our range of audio devices, who can apply, as well as user manuals and instructions.

Please note that devices that require a professional referral can only be selected if you’ve selected ‘sight loss or support professional’ in the referrer details section of this form.

Further information

Why are you applying for this device? *

Please tell us a little about how this audio device would benefit you (or how it would benefit the person receiving the device, if you are referring someone else). We only use this information to review and improve our services. It won’t be used to inform our decision about whether we award an audio device.

Confirmation

British Wireless for the Blind Fund (BWBF) would like to keep you informed of our future services, events and fundraising activities.

I am happy to be contacted by BWBF (if you are referring someone else please tick if the person you are referring has indicated that they are happy to be contacted by BWBF).

This audio device is on loan and remains the property of British Wireless for the Blind Fund (BWBF). Please notify BWBF if things change, and you no longer meet our eligibility criteria. Please do not give away or sell the device. If the device is damaged or stops working, please notify BWBF.

I agree to these terms and conditions (if you are referring someone else please tick to indicate that you have conveyed these terms and conditions to the person receiving the device). *