Student Support Registration Form

* Family Name

* First Name

Preferred Name (if different from your legal name)

Please note that DSA regulations require any correspondence relating to session authentication to be issued in your legal name. All other correspondence from our office can be sent using your preferred name.

Preferred Pronouns

* Home Address

* Term-Time Address

Town/City

Post Code

Phone

* Mobile

Academic Email Address

* Personal Email Address

Date of Birth

CRN (SLC Customer Reference Number)

* Course type

* Degree level

* Course of Study

* Institution Name

Is support required on a specific campus, or online?

* Date of Enrolment (DD/MM/YYYY)

Year of Study (e.g. 1st, 2nd, 3rd)

Duration of Course (e.g. 1 year, 2 years, 3 years)

* Expected Course End Date (DD/MM/YYYY)

Nature of Disability

Type of Support

Hours of Support Awarded

* Are you completing this form on behalf of someone else? Yes No

* Would you prefer First Class Support to discuss your support arrangements with another person, such as a parent or primary carer? Yes No

* Full Name

* Contact Details

* Relationship/Capacity Known

* Does your course include a placement or year abroad? Yes No

* Do you consent to us discussing your support with your university Disability Advisor if required to help arrange or deliver your support? (You may request copies of any correspondence at any time.) Yes No

* Disability Adviser Name

* Disability Adviser Contact Details

* Please explain why you do not wish for us to contact your Disability Advisor.

* DSA/ATW or other funding body letter

Needs Assessment Report

Emergency Contact Details:

We will only use these details in the event of a welfare or safeguarding concern where it is appropriate to do so.

* Emergency Contact Name

* Emergency Contact Telephone Number

* Relationship to You

I understand that First Class Support may share information without my consent where there is a safeguarding concern, risk of harm, or legal obligation to do so, in line with its Safeguarding Policy. Where appropriate, this may include contacting my emergency contact or other relevant parties if there are concerns about my welfare or safety.