Philippine Registry for Persons with Disabilities

Registration Page

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3. Last Name *
First Name *
Middle Name *
4. Type of Disability *
5. Causes of Disability
6. Address - Number & Street Name *
Region *
Province *
City/Municipality *
Barangay
7. Contact Details:
7.a. Landline Number
7.b. Mobile Number
7.c. Email Address
8. Birthday *  Pick a date
9. Sex *
   
10. Civil Status *
11. Educational Attainment
12. Employment Status
13. Nature of Employer
14. Type of Employment
15. Occupation
Others - please specify
16. ID Reference No.
SSS Number
GSIS Number
PAGIBIG Number
PHIC Number
PHIC Status
17. Blood Type
18. Organizational Information:
Organization Affiliated
Contact Person
Office Address
Contact Number
19. Parental Information:
Father's Last Name
Father's First Name
Father's Middle Name
Mother's Last Name
Mother's First Name
Mother's Middle Name
Guardian's Last Name
Guardian's First Name
Guardian's Middle Name
20. Accomplished By
Username *
Password *
Confirm Password *

 

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