Online Application Form

Welcome

Thank you for your interest in becoming a Blind Country member. Please complete the following form and we will be in touch with you soon.

Please enter your personal details:
Your Name
  Country
  Telephone
  Mobile
  Email
  Re-type Email

What is your preferred contact method:




What is your age range:







What is your degree of visual impairment:





I am currently:





I am interested in (check all that apply):

What kind of computer do you currently own:





What kind of smartphone do you currently own:





How clear is your speech (required to use the speech interface):



How would you rate your hand motor-skills (required to use the touch interface):



How many trusted helpers (friends, family or work colleagues) would you allow to help maintain your details:




How did you first hear about Blind Country:





  Details:

SUBMIT