ABBF PwD & Caregiver Vaccination Drive, India

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Adventures Beyond Barriers Foundation, ABBF, is a not for profit working towards Disability Inclusion and empowerment. The current pandemic has disproportionately impacted People with Disability, with more of them contacting and losing lives than any other minority community in the world. They are struggling to get vaccinated which can keep them safe. Hence we are undertaking this initiative through our amazing volunteers and champions to facilitate ease in vaccination for People with Disability living in India.

While ABBF will make a reasonable effort to facilitate PWD's to reach the vaccination center for those who absolutely need it, ABBF cannot commit to organising transport for all PWD's. Please note that not being able to reach the vaccination center independently may delay your ability to get vaccination.

If you are a Person with Disability, who wants to get COVID-19 vaccination, please fill this form and our team will coordinate with you.

PLEASE NOTE

This form is valid for one person only. To register more than one person, please fill and submit this form again with new details.

I am a *

Person with Disability

Care-giver

Transgender

Which NGO are you associated with (if any) ?

What is your full name? *

Which gender identity do you most identify with?

Male

Female

Transgender female

Transgender male

Not listed

I prefer not to answer

Clear selection

When is your birth date? *

Please ensure you enter full 4 digits of your year of birth correctly. Please do not enter 1982 as 82.

YYYY

What is your primary MOBILE number? *

Only 10 digits of the number. Please DO NOT prefix 0 or +91 or anything else.

What's your primary address? *

What is your area pin code ? *

What is your Aadhaar card number? *

Please enter all zero ( 0 ) in case you do not have Aadhaar Card Number.

What disability do you have? This will help us understand your needs better. You may tick more than one option, if applicable. *

No disability (Caregiver)

Blind

Low vision

Leprosy-cured person

Hearing impairment

Locomotor disability

Dwarfism

Intellectual disability

Mental illness

Autism spectrum disorder

Cerebral palsy

Muscular dystrophy

Chronic neurological condition

Specific learning disability

Multiple sclerosis

Speech and language disability

Thalassemia

Haemophilia

Sickle cell disease

Multiple disabilities including deaf blindness

Acid attack victims

Parkinson’s disease

Required

Do you have any other co-morbid medical conditions? (e.g. - Diabetes, blood pressure, auto-immune disorders etc)

This is an optional question.

Yes

I don't know

Clear selection

Are you allergic to any drugs?

This is an optional question.

Yes

Clear selection

Have you received the 1st dose of Covid vaccine earlier? *

Yes

If YES, which vaccine dose have you received? *

Choose Not Yet if you have not got any vaccine yet, other wise let us know the name of the first dose.

Not Vaccinated

Covishield

Covaxin

If YES, when did you get your first dose (approximately) ?

YYYY

Have you tested COVID-positive in the last 10 weeks ? *

Yes

Can you afford to pay for your vaccination?

This is an optional question.

Yes

Clear selection

Have you been registered on COWIN or Arogyasetu app ? *

(Registration on the government portal is mandatory for Vaccination)

Yes

Can you travel to Vaccination center on your own or with your care giver ?

This is an optional question.

Yes

Clear selection

Do you have a disability Certificate issued by any government body ?

This is an optional question.

Yes

Clear selection

Declaration *

I understand that Adventures Beyond Barriers Foundation is only facilitating the ease of vaccination. I do not hold them responsible for inability to get vaccinated for any reason and any untoward or adverse reaction from the vaccination.

Required

Submit

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