Goldsmiths - University of London

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Appointment Request Form

Title: *
First name: *
Surname: *
Address: *
  *
Town/City: *
Postcode: *
Telephone number: *
E-mail address: *
Is it OK to email you?
Is it OK to contact you by phone?
Is it OK to leave messages?

Availability

Please check ALL times you can attend and appointment

  9-10 10-11 11-12 12-1 1-2 2-3 3-4 4-5 5-6
Monday
Tuesday
Wednesday
Thursday
Friday
If you wish to see a particular Chaplain then please state who:
Is there is anything else you feel you need to tell us at this stage about this appointment request?:

The information which you provide on this form will be used only for the purposes of arranging an appointment with one of the Chaplains, and any appropriate follow-up actions agreed with you. It will be stored only until the conclusion of the appointment and any follow-up actions agreed. The information provided will not be disclosed to anyone outside the College without your consent.

I understand that the personal data which I have provided on this form may be stored in paper and/or electronic form in accordance with Goldsmiths College policies on Data Protection and with the provisions of the Data Protection Act (1998).