Apply for a Keep Safe Card

If you have a learning disability you can apply for a Keep Safe Card by filling in the online form on this page.

We will then send you a Keep Safe Card through the post. The card will have space on it to write your name, address and the emergency contact details of the person who you would want to be told if you were in trouble.

The card also has space for you to write information about any medication you take, how you prefer to communicate and anything else you might want someone to know about you.

You will also be sent an instruction card (you can find an example of this attached to this page) which will help you fill in and use the Keep Safe Card.

If you feel scared, threatened or are in trouble while out and about you can go to a Safe Place to get help.

You can find a Safe Place near you by looking on the map on the Derbyshire Safe Place Scheme page.

If you would like to talk to somebody about the Safe Place Scheme, please email: clare.waterfall@derbyshire.gov.uk or tel: 01629 532469.

An easy read version of the application form is attached to this page.

I already have a Keep Safe Card

Even if you already have a Keep Safe Card we would appreciate it if you filled in the form on this page. This is because we want to keep a list of people who have the cards. You just need to fill in the form with your details and tell us where you got the card from (usually your day centre or from your support worker).

Related documents

The following document is in Portable Document Format (PDF). You can download software to view PDF documents for free from the Adobe website (opens in a new window)

The following document is in Word format. You will need a Word viewer installed on your computer in order to open these files.

Also on our website

Derbyshire Safe Place Scheme - application for a Keep Safe Card

Note: Asterisks (*) indicate required information.

errorPlease correct the information in the fields highlighted below.
Personal details


















Card information






Disclaimer

Data Protection Act
We will, with your permission, keep your contact details on a database. We undertake to safeguard your information and will only use it for Derbyshire Safe Place Scheme business.
Please inform us of any changes to your contact details and if at any time you wish to stop using your Keep Safe Card, let us know and we will remove your name from the database.



If you experience any problems with this form please contact contact.centre@derbyshire.gov.uk and quote form ID: ILF/369/09