Goldsmiths - University of London

SECTION A - Personal Details

Email*

Title*

Forenames*

Surname*

Address*

Post code*

Contact number*

Reference number

Programme/Course name

Course reference

Year of entry*

SECTION B - About your disability

(i.e. impairment/s, health condition, specific learning difficulty etc

Please describe your health condition, disability or specific learning difficulty*

Please tell us about any specific support or adjustments you feel you might need from Goldsmiths.
(e.g. extra time for exams, study skills support, note taker, sign language interpreter, support worker etc.)

Would you require assistance to exit the college premises in an emergency? (e.g. if you have severe visual impairment, difficulties in using stairs or hearing alarms etc.)
Yes No

Do you have any disability or health related requirements for College Accommodation (Please tick no, if you are not applying for accommodation)
Yes No

Please note that if you have any disability/health related requirements you are advised to apply for accommodation as soon as possible to ensure that we can attempt to meet your accommodation needs. To apply for accommodation visit: http://www.gold.ac.uk/accommodation/

SECTION C - Disabled Students Allowance

Is there any other information you feel would be helpful for us to be aware of?

Do you give permission for the information relating to your disability to be circulated to other members of Goldsmiths staff. This would only be done if it was necessary to ensure we can arrange any support or adjustments required.
Yes No

Would you like the opportunity to come in and discuss your needs with one of the Disability Team before enrolment?
Yes No

If you tick yes we will contact you to arrange it.

SECTION D - Declaration

PLEASE READ THE DECLARATION BELOW