Blue Badge Application Form
Unable to walk or virtually unable to walk
Please complete all relevant sections of the application form and supply the appropriate documents to confirm your address, identity and evidence of eligibility. When completing this form you may find useful information on Blue Badge eligibility at: www.mygov.scot/apply-blue-badge/eligibility.
The local authority may refuse to issue a badge if you do not provide adequate evidence that the eligibility criterion is met.
If you are completing the form on behalf of an applicant who is under 16 years old or is unable to complete the form themselves, please provide their details in the appropriate sections and sign the form on their behalf.
Information about the applicant
Title (Mr, Mrs, Ms, other):
First name(s) (in full):
Surname:
Surname at birth (if different):
Date of birth (DD/MM/YYYY): D D M M Y Y Y Y
Place of birth (town and country):
National Insurance Number (16 and over)/NHS Number (under 16)
The NHS number is made up of 10 digits, usually shown in a 3-3-4 format.
Driving Licence Number (if applicable):
Current address & postcode:
Information about the applicant
Previous address, if different in the last three years:
Telephone (home):
Telephone (mobile):
Email address:
Do you currently hold a Blue Badge, or have you held a Blue Badge before?
☐ Yes
☐ No
If yes:
Which local authority issued you with the last badge?
What is the serial number on the last badge? The serial number can be found on the front of your badge.
What is the expiry date of the last badge?
Proof of your address
We need to check that you are a resident in this local authority area before we can process your application. Please select one of the following options and provide copies of the original documentation where relevant:
☐ I have enclosed a Council Tax bill bearing my name and address, dated within the last 12 months.
☐ I have enclosed a utility bill bearing my name and address, dated within the last 3 months.
☐ I do not pay Council Tax, am over the age of 16 and submit a copy of my lease as proof of my address.
☐ I give consent to the local authority to check my personal details on the local authority’s Council Tax/Assessor and Electoral Register or National Entitlement Card systems to confirm my address.
☐ I am applying on behalf of an applicant who is under 16 and submit a copy of an NHS letter to prove their address.
☐ I am applying on behalf of an applicant who does not pay Council Tax and is under the age of 16. I give my consent to the local authority to check school records to confirm their address.
The name of the applicant’s school is:
Proof of your identity
We need to check your identity to reduce the potential for fraudulent applications for a Blue Badge. You must attach a photocopy of one of the following as proof of your identity. Do not send original documents as these will not be returned.
Birth/Adoption certificate
Marriage/Divorce certificate
Passport
Civil Partnership/Dissolution certificate
Valid driving licence
Photograph
Please enclose a recent passport-quality photograph of the applicant. The photograph needs to show the applicant’s full face so that the holder can be easily identified. No one else should be in the photograph.
Applicants who are unable to access photo booths can provide a suitable clear photograph taken by other means (*e.g. mobile phone, tablet or digital camera) which can be cut down to an appropriate size.
Please ensure that the applicant’s name is on the back of the photograph and complete the declaration at the back of the form to confirm that the photograph is a true likeness.
Badge Fee
If your application is successful you will receive a letter/email/telephone call requesting payment of £20 for your badge. Your Local Authority will only issue successful applicants with a Blue Badge once payment has been received.
Payment information specific to Orkney Islands Council
The fee for a new badge or renewal is £20.00. Payment can be made by cash, cheque, postal order or debit or credit card. Cheques should be made payable to: Orkney Islands Council. Payment will only be taken if your application for a Blue Badge is successful. You will only be issued with a Blue Badge once your payment has been received.
Where possible, please nominate the vehicle registration number(s) for the main cars in which you intend to use the Blue Badge:
(Up to three registration numbers should be nominated, but please remember that other vehicles can be used.)
Confirming your eligibility
Please note that you will only qualify for a Blue Badge under this criterion if you, or the person on whose behalf you are applying, are over two years of age and:
have a permanent and substantial disability which means you/they are unable to walk or virtually unable to walk; (a permanent disability is one that is likely to last for the duration of your life,) or
have a temporary, but substantial disability, which means you/they are unable to walk or virtually unable to walk which is likely to last for a period of at least 12 months, but less than 3 years.
1. Please select one of the following to confirm why you would benefit from a Blue Badge:
☐ I am unable to walk, or virtually unable to walk due to a permanent and substantial disability.
☐ I am unable to walk, or virtually unable to walk by reason of a temporary but substantial disability which is likely to last for a period of at least 12 months, but less than 3 years.
2. Please provide the name of the medical condition(s) or disability/disabilities which have led to your Blue Badge application.
3. Do you have a terminal illness that seriously limits your mobility?
☐ Yes
☐ No
4. Are you currently receiving care and support from palliative care services such as Macmillan Cancer Support?
☐ Yes
☐ No
5. Have you been issued with a DS1500 or BASRiS form?
☐ Yes
☐ No
☐ I can confirm I have attached a copy of my DS1500 or BASRiS form.
6. Please describe any surgery or courses of treatment you have undergone or specialist clinics you have attended in relation to improve the conditions that make your walking difficult.
7. Please state when you underwent any relevant surgery or treatment or attended specialist clinics.
| Surgeries/courses of treatment/specialist clinic | Dates you received this treatment |
|---|---|
8. What medication do you currently take in relation your breathing or walking difficulties?
| Medication | Dosage | Frequency |
|---|---|---|
Should you wish to provide a recent prescription to support your application, you may do so.
I have attached a recent prescription to support my application:
☐ Yes
9. Are you currently taking any pain relief to improve your ability to walk?
☐ Yes
☐ No
If yes, please explain what you are taking and how frequently have you been prescribed to take it.
10. Are you currently...
☐ Awaiting surgery in relation to the conditions/disabilities described above?
☐ Recuperating from surgery in relation to the conditions/disabilities described above?
☐ Awaiting treatment for any of the conditions/disabilities described above?
☐ Managing your condition/disability since you have been advised it is not expected to improve any further?
☐ None of the above.
11. Please give details of the regulated healthcare professionals, or specialists (including your GP) who have been treating you in relation to the conditions/disabilities described above:
| Name | Job Title | Hospital/Health Centre | Phone Number |
|---|---|---|---|
12. Have you been advised by a regulated health professional that walking is beneficial for you?
☐ Yes
☐ No
13. Have you been advised by a regulated health professional that walking is detrimental or dangerous for you? If so, please provide their details in the table above.
☐ Yes
☐ No
If you ticked Yes, please provide details of their advice:
14. Do you anticipate that your conditions/disabilities will improve in the next 3 years?
☐ Yes
☐ No
If you ticked Yes, please describe how much you expect your conditions/disabilities to improve:
15. Please tick all of the following statements that describe your general walking ability
☐ I am able to walk well, including recreational walk.
☐ I am able to walk around the supermarket to do my own shopping.
☐ I am able to walk and can use public transport for some of my local trips.
☐ I am able to walk, but struggle with longer distances or hills.
☐ I am able to walk, but get severe breathless related to my medical condition(s) if I walk for more than a few minutes.
☐ My level of pain causes me to stop walking more often than not.
☐ I am able to walk around my home, but am unable to climb the stairs.
☐ I am a full-time wheelchair user.
☐ Other, please describe below:
16. Are you able to walk outside alone (not including the use of a walking aid), or do you need someone to assist you?
☐ Yes
☐ No
If No, please describe the help you need below:
17. Where, in your local area, can you comfortably walk to before you feel discomfort?
This could be from your home or another specific location.
(Please state each specific location or landmark which could be found on a map, e.g. a shop, street address or park) *Local Authorities can check this on via an online mapping tool to provide them with an accurate distance.
18. Please tick the box that best describes the way you walk
☐ No specific problems with walking.
☐ You walk with a slight limp.
☐ You walk with a heavy limp, a stiff leg or shuffle, or have problems with balance.
☐ You drag your leg, stagger, swing through two crutches or need physical support.
If there is not a box that describes the manner of your walking (your gait), please tell us in your own words about the way you walk in the space provided below, if pain impacts on your gait please include details on the location and nature of the pain:
19. Have you been seen by a healthcare professional in the past 12 months due to falls?
Please provide details:
20. Do you use any of the following walking aids?
☐ 1 elbow crutch
☐ 2 elbow crutches
☐ 1 walking stick
☐ 2 walking sticks
☐ Walking frame/Zimmer
☐ Rollator (walking frame with wheels)
☐ Wheelchair
☐ Powered wheelchair
☐ Other, please describe below:
21. Were your walking aids...
☐ Purchased privately by me
☐ Prescribed by a healthcare professional
☐ Provided by Social Services
☐ Other (please describe below)
Wheelchair users
If you selected ‘wheelchair’ above, please answer the following 3 questions:
22. Please tick which applies to you:
☐ Wheelchair
☐ Powered wheelchair
23. Was your wheelchair:
☐ Purchased privately by me
☐ Prescribed by a healthcare professional
☐ Provided by Social Services
☐ Other (please describe below)
24. Do you use your wheelchair all the time, indoors & outdoors?
☐ Yes
☐ No
If No, please describe when you use your wheelchair and explain why?
Confirming your eligibility
Please answer ‘Yes’ or ‘No’ to each of the following questions:
25. Do you get severe breathlessness or struggle to hurry on flat ground or to walk up a slight incline/hill, due to a medical condition?
☐ Yes
☐ No
26. Do you need to pause for breath after walking a short distance on flat ground?
☐ Yes
☐ No
27. Do you struggle to walk and talk at the same time?
☐ Yes
☐ No
28. Do you get severe breathlessness related to a medical condition in the house when walking from room to room?
☐ Yes
☐ No
29. Is there anything else you would like to add that you think is relevant in support of your application for a Blue Badge?
Please note you can also attach copies of consultant, result, hospital discharge and prescriptions letter or patient summaries.
I have attached medical letters/documentation to support my application:
☐ Yes
Declarations and Signatures
These questions are intended to be answered by all Blue Badge applicants.
Please read the following declarations thoroughly and tick all of the relevant boxes to indicate that you have read and understood each declaration. Not ticking one of these declarations may mean we are unable to issue you with a Blue Badge. Providing fraudulent information may result in prosecution and a fine.
All documents relating to this application will be dealt with in line with the Data Protection Act 2018, UK General Data Protection Regulation (GDPR) and may be shared within the local authority, with other local authorities, the police and parking enforcement officers to detect and prevent fraud. We also have our own Privacy Policy, details of which can be found on our website.
Any medical information that you have supplied to support this application is deemed, under the Data Protection Act 2018, to be “sensitive personal data” and will only be disclosed to third parties as necessary for the operation and administration of the Blue Badge scheme, and to other government departments or agencies, to validate proof of entitlement or as otherwise required by law.
Declarations to be completed by applicant
☐ I can confirm that, as far as I know, the details I have provided are complete and accurate. I understand that action may be taken against me if I have provided false information in this application form.
☐ I understand that I must promptly inform my local authority of any changes that may affect my entitlement to a Blue Badge.
☐ I confirm that the photograph I have submitted is a true likeness.
☐ I understand that, if my application is successful, I must not allow any other person to use the Blue Badge and I must only use the Blue Badge in accordance with the rules of the scheme as set out in the Rights and Responsibilities leaflet that will be sent to me with my Blue Badge.
☐ I understand I must not hold more than one valid Blue Badge at any time.
☐ I consent to the local authority contacting a regulated healthcare professional for the purpose of obtaining further information in support of my application.
☐ I understand that I may be required to undertake an assessment with a regulated healthcare professional who is independent of my existing care and treatment, in order to determine my eligibility for a Blue Badge.
☐ I consent to the local authority having access to my medical notes where their systems allow.
Misuse of a Blue Badge is a criminal offence.
Your consent to use your information to improve the service you receive
Please read and tick the following declarations that you consent to. Ticking these boxes will help us to improve the service we can offer.
☐ I consent to my local authority checking any information already held by their Social Services department on the basis that:
It can help determine my eligibility for a Blue Badge.
It may speed up the processing of my application.
It may enable a decision to be made without the need for a mobility assessment.
☐ I agree to the disclosure of information included in this form to other local authority department/service providers so that I can be informed about other services that may be of benefit to me.
Checklist of documents you may need to disclose
Please ensure that you have enclosed copies of all of the relevant documents for the sections of this application form. Copies should be true likeness of the originals. Please tick the relevant box(es) below to confirm all documents/photocopies provided are genuine:
☐ Copy of letter from your Doctor or Healthcare Specialist to support your application, including any other supporting medical documentation
☐ Copy of your DS1500 form or BASRiS form, if applicable
☐ Copy of a recent prescription, if applicable
☐ Document to prove your address, as listed in the ‘Information about the applicant’ section
☐ Document to prove your identity, as listed in the ‘Information about the applicant’ section
Your signature against the declarations
Applicant’s signature:
Date of application (DD/MM/YYYY): D D M M Y Y Y Y
Please print your name:
Submitting your application
Please return this form and relevant documents to:
Customer Services (Blue Badge Application)
Orkney Islands Council
Council Offices
School Place
Kirkwall
Orkney
KW15 1NY
IMAGE: The form’s cover page identifies it as the “Blue Badge Application Form” for people unable to walk or virtually unable to walk. It displays the Orkney Islands Council crest and logo and the Transport Scotland logo, and provides fields for the applicant’s personal details, date and place of birth, National Insurance or NHS number, driving licence number, and current address and postcode.