---

Dear Registrant,

We are pleased to provide you with the Disability Living Allowance application form. To ensure a smooth processing of your application, please take a moment to review and provide accurate information.

Once submitted, your application will be carefully reviewed, and you will be contacted if you qualify for the allowance.

Note that we will only consider children aged 3-16.

Best regards!

---

Child's Profile Information

Full Name*

Diagnosis*

Age(in years)*

Gender

Male

Female

Image(1MB max)*

Different image(1MB max)*

Home Address*

More Information about the child*

---

Parent's/Guardian's Information

Full Name*

Email Address*

Phone Number(Whatsapp preferred)*

Occupation*

Bank Name*

Account Number*

Account Name*

---

Other Info

Doctor's Name*

Hospital*

School Name*

School Address*

---

Mother Mi treats personal information information carefully but may use it for any of our purposes. I authorize Mother Mi to use any of the information I submitted for their purposes.

If Mother Mi decides not to process my application, I will not hold her responsible whether in court of law or take any further action.

Submit