Prospective student online form

Please complete this form to let us know about any specific requirements you have whilst you are at university. Please ensure that you have your medical evidence or Educational Psychologist report ready to upload before completing this form.

Please be aware that if you submit your form after 31st July 2019 we may not be able to put your support in place before the start of your course. We therefore encourage you to complete the form as soon as possible.

If you consider your needs to be quite complex, and adjustments are likely to go beyond the standard baseline adjustments, it is really important you contact Wellbeing Services well in advance of your studies (e.g. if you require practical assistance during your studies, or equipment to be in place when you start, or you need adaptations to your accommodation such as a hoist).

Informing us of your consent

Depending on your individual support needs your information may be shared with the following people as appropriate:

Your College
Exams Team
Accommodation and Estate team
Health and Safety Office

Please ensure you read the following with regards to how your information may be shared with other staff within the University - Declaring a Disability or Health Condition. Please see our Privacy Notice if you have any queries with regards to your personal data.

Please note: any correspondence we send you will be sent to the email address you used in your UCAS application (or your direct application if you didn’t go through UCAS). Please ensure this is your own email address and is up-to-date, as otherwise you may not receive important updates from our advisors; for example, if you applied using your college email address this may become deactivated in the coming months. Please click here for instructions on how to update your email address with UCAS.

If you declared your disability/health condition on your UCAS application, you will receive an email from us asking you to fill out this form. However, please be aware that you do not need to wait to receive this email in order to fill out the form - the sooner we receive your information, the sooner we can start arranging your support, so please get in touch.

First name: *
Surname: *
Exeter Reference Number: e.g. 612345678
Date of birth e.g. 20/09/1988:
Mobile number:
Course name:
Which campus will you study on?
Start date:
1) Please complete the following declaration by ticking the relevant disability/health condition below. You can select more than one.	Specific learning difficulty eg dyslexia, dyspraxia, AD(H)D Blind/visual impairment Wheelchair user/mobility difficulties Deaf/hearing impairment Asperger's Syndrome/Autism Mental health difficulties Two or more disabilities/health conditions (please specify in question 2) Other conditions (please specify in question 2)
2) Please describe your medical condition/physical disability/mental health or specific learning difficulty:
3) What academic/support adjustments have you had in the past? Please note this will not automatically continue at the University.
4) Do you have specific requirements for your accommodation due to a health condition or disability? Please give details.
5) If you would like to give us any further details about your support requirements, please do so here:

Medical evidence upload field
Please ensure you upload medical evidence with this form as otherwise we will not be able to process it. (Please see ‘Medical Evidence – Guidance’ on the previous page if you are unsure what you need to submit)
Please upload any relevant medical evidence here: *
Further evidence:	+
Further evidence:

Health and Safety
In the event of an evacuation are you able to (at all times, including during a medical episode such as a seizure): A) Independently leave the building in a reasonable time, including use of stairs?
B) Hear the fire alarm, at all times (including during a medical episode such as a seizure, and when in bed and in the shower)?
C) If you've answered 'no' to question A) or B) above, please give further details:

Declaration
I confirm that the above information is correct to the best of my knowledge and that I have read the document ‘Declaring a Disability or Health Condition’ . I will inform Wellbeing Services of any change in my circumstances. I consent to my information being shared as outlined above. *
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