Forms home Disabled Persons Freedom Pass application Your detailsTitle First name* Last name* Date of birth* DD slash MM slash YYYY Age* National Insurance Number For those over 16 years oldCurrent address* Street Address Address Line 2 Postcode How long have you been at this address?* Less than 3 years More than 3 years Previous address* Street Address Address Line 2 City Postcode Contact telephone numberEmail address Have you ever held a Freedom Pass or National Bus Pass?* Yes No Which council issued it? What is the expiry date? DD slash MM slash YYYY Have you previously applied for a Blue Badge?* Yes No Could we use your Blue Badge application to help us with your Freedom Pass application?* Yes No Using your Blue Badge application means we can use the evidence you may have submitted before and help progress your Freedom Pass application.Information about your disabilityPlease select the boxes that apply to you* I am blind or partially sighted I am severely or profoundly deaf I am without speech I have a disability or have suffered an injury which has a substantial and long-term adverse effect on your ability to walk I do not have arms or have long-term loss of use of both arms I have a learning disability I would be refused a driving licence, other than on the grounds of persistent misuse of drugs or alcohol Blind or partially sightedAre you registered in Redbridge?* Yes No Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a copy of your BD8 certificate or your Certificate of Visual Impairment (CVI). We cannot accept letters from GPs or Dispensing Opticians.Severely or profoundly deafAre you registered in Redbridge?* Yes No Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent copy of your Audiogram or Audiology Report. We cannot accept letters from GPs.Without speechAre you registered in Redbridge?* Yes No Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a copy (dated within 12 months) of your Personal Independence Payment (PIP) award letter which shows a score of 8 points or more for "Communicating verbally" or a recent detailed report from your GP or Speech Therapist.Disability or injury which affects your ability to walkDo you receive Disability Living Allowance (DLA) at the Higher Rate of Mobility (HRM)?* Yes No Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent copy of your Disability Living Allowance award letter. Your award letter must be dated within 12 months and at your current address. It must show the rate of the award and the expiry date. If your award is indefinite, you must call the DWP and ask for a recent copy. To contact the DWP, please call 03457 123 456.Do you receive Personal Independence Payment (PIP) with a score of 8 points or more in the 'Moving Around' activity of the Mobility component?* Yes No This does not include points for 'Daily Living' or 'Planning and following journeys'Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent copy of your Personal Independence Payment (PIP) award letter. Your award letter must be dated within 12 months and at your current address. The letter must show a complete breakdown of the points awarded in each category, and the expiry date. We do not accept Christmas bonus letters or Motability certificates, or only the entitlement summary page. To contact the DW for a copy of your PIP letter, please call 03457 123 456.Do you receive the War Pensioners' Mobility Supplement (WPMS)?* Yes No Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent copy of your War Pensioners' Mobility Supplement award letter.Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent report from your GP or Consultant confirming: Details of your disability or condition How long you have had the disability or condition How long the disability or condition is expected to last How the disability or condition affects your ability to mobilise and walk If you require a walking aid, what type of walking aid and how regularly it is used A list of your prescribed medication or a copy of a repeat prescriptionNo arms or long-term loss of use of both armsProof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent medical report detailing your condition.Learning disabilityAre you registered with, or receiving services from, the Redbridge Learning Disabilities Team?* Yes No Proof needed* Drop files here or Select files Max. file size: 10 MB. If you are not registered, please provide a copy of 1 of the following: Statement of Educational Needs (SEN) Education, Health and Care Plan (EHC) Letter from the Children with Disabilities Team A recent psychological assessment Letter from your specialist school Being issued with an SEN/EHC does not guarantee eligibility for a pass but may help our assessment. We cannot accept letters or reports from GPs regarding a learning disability.Details to discuss supporting evidence If we need to discuss your supporting evidence with the person who provided it, or your support worker, please confirm if you agree for us to do this and provide their informationI agree for you to discuss my supporting evidence with the person who provided it. I agree Contact name Contact telephone numberRefused a driving licenceHas the DVLA already refused or revoked your driving licence? Yes No Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent copy (within 6 months) of your refusal or revocation letter from the DVLA or a recent detailed report (within 3 months) from your GP or Consultant which confirms your medical condition and why you are legally considered medically unfit to drive.If you do not have a recent letter from the DVLA, you will need to have provided evidence by selecting one of the conditions listed on this form. We are not asking you to apply to the DVLA if you do not already have this letter, however, your condition must still be such that you would legally be barred from driving other than on the grounds of persistent misuse of drugs or alcohol. Please select why you would be refused a driving licence* I have epilepsy I have a severe mental disorder I am liable to sudden attacks of giddiness or fainting I am unable to read a registration plate in good light at 20.5 metres (with lenses, if worn) I have another disability which is likely to cause the driving of a vehicle by you to be a source of danger to the public EpilepsyProof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent report from your GP or Consultant confirming: Your specific diagnosis How often you have an epileptic attack The date of your most recent epileptic attack If your epileptic attacks happen whilst you are awake, asleep or both Your relevant prescribed medication Being issued with an SEN/EHC does not guarantee eligibility for a pass but may help our assessment. Severe mental disorderDo you regularly see a psychiatrist? Yes No Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent report from your Psychiatrist, CPN or Support Worker confirming: Your specific mental health diagnosis Whether there is any misuse of drugs or alcohol How often you see your psychiatrist To what degree your condition affects your concentration, memory or behaviour Your prescribed medication, including dosage, and any side effects you may experience Whether your condition is in the acute stage or whether you are currently stable The impact of your condition on your daily life and any relevant problems you encounter What services you attend and how often you attend Do you have a current Care Plan? Yes No Proof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a copy of your complete Care Plan dated within 12 monthsDo you receive Disability Living Allowance or Personal Independence Payment? Yes No Proof needed*Max. file size: 10 MB.Please upload a copy of your Disability Living Allowance or Personal Independence Payment. Your award letter from the Department for Work and Pensions (DWP) must show your current address be dated within 12 months and show the rates of the award or points awarded and expiry date. We do not accept Christmas bonus letters or Motability certificates or only the entitlement summary page. To get a copy of your award letter, phone the DWP on 08457 123 456To be able to apply for the disabled persons Freedom Pass you need to submit proof of your disability. If you do not have a psychiatrist's report, care plan, Disability Living Allowance or Personal Independence Payment proof you will need to provide alternative evidence. What proof are you uploading?*Proof needed* Drop files here or Select files Max. file size: 10 MB. Giddiness or faintingProof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent report from your consultant confirming: Details of your disability or condition How long you have had this disability or condition How long your disability or condition is expected to last Your relevant, prescribed medication Why you do not currently meet the DVLA requirements to drive Unable to read registration plate at 20.5 metresProof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent report from your consultant confirming: Details of your disability or condition How long you have had this disability or condition How long your disability or condition is expected to last Your relevant, prescribed medication Why you do not currently meet the DVLA requirements to drive Another disabilityProof needed* Drop files here or Select files Max. file size: 10 MB. Please upload a recent report from your consultant confirming: Details of your disability or condition How long you have had this disability or condition How long your disability or condition is expected to last Your relevant, prescribed medication Why you do not currently meet the DVLA requirements to drive Proof of address, identity and photographProof of identification* Drop files here or Select files Max. file size: 10 MB. Please upload a copy of one of the below: Passport Photo driving licence Birth certificate Medical card Proof of address* Drop files here or Select files Max. file size: 10 MB. Please upload 2 copies of the below, dated wihin 3 months unless stated: Utility bill (gas, water, electricity) Council Tax bill TV licence Tenancy agreement Driving licence (if not used as ID) DWP award letter (dated within 12 months) Job Centre letter Bank statement For those under 16 years old, or with a guardian, we need at least one proof in your name. The second proof can be in the family/guardian's name if it is at the same address.PhotographAccepted file types: jpg, jpeg, Max. file size: 10 MB.Please upload one recent colour passport sized photograph of yourself (unless you currently hold a Freedom Pass): In colour, against a light, plain background Without sunglasses, dark glasses or hats unless for medical reasons A natural look whilst facing forward, with the whole head showing Without head covered, unless for religious or medical reasons. We can only accept jpg format files. This is the standard photo file format and will most likely be the format of any photo taken on a standard device.
