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Speaking Up

Have your say to make a difference

I would like a place on the course. Please let me


know if I can come.

My name

My address

My phone
number

My email

The University can support you better if we


My know what disability you have.
Learning Please fill in the rest of the form.
support If you need help with the form please ask.
needs
The University needs to know if you have
convictions that are not spent.
My criminal This is to make sure that you and other
students and staff are safe.
record Please fill in the rest of the form.
If you need help with the form please ask.
Disability/special needs

If you have a disability, special needs (including dyslexia or


another specific learning difficulty) or a medical condition, please
select the most appropriate option from the list. If you do not have
a disability, special needs or a medical condition, select 'No
disability'. If you do not want to give this information now, you
should select 'No disability'. However, you should tell your chosen
universities or colleges as soon as you receive our welcome letter.

Disability or Special Needs code

Please enter the code from the list on the next page, if you have a
physical or sensory disability which may affect your studies.

Please tell us about any special needs for facilities or support you
have because of your disability or medical condition.
Disability, special needs or medical condition codes:

0. No disability
1. You have a social/communication impairment such as
Asperger's syndrome/other autistic spectrum disorder
2. You are blind or have a serious visual impairment uncorrected
by glasses
3. You are deaf or have a serious hearing impairment
4. You have a long standing illness or health condition such as
cancer, HIV, diabetes, chronic heart disease, or epilepsy
5. You have a mental health condition, such as depression,
schizophrenia or anxiety disorder
6. You have a specific learning difficulty such as dyslexia,
dyspraxia or AD(H)D
7. You have physical impairment or mobility issues, such as
difficulty using your arms or using a wheelchair or crutches
8. You have a disability, impairment or medical condition that is
not listed above
9. You have two or more impairments and/or disabling medical
conditions

Criminal convictions

To help the universities and colleges reduce the risk of harm or


injury to their students and staff caused by the criminal behaviour
of other students, they must know about any relevant criminal
convictions that an applicant has. Please read the following
carefully.

If you have a relevant criminal conviction that is not spent, please


tick the box; otherwise leave it blank.

Criminal Convictions
If you have a relevant criminal conviction, enter X in the box

Yes
If you tick the box you will not be automatically excluded from the
application process. You do not need to provide any details of
your conviction now. However, the university or college may ask
you to provide further information at a later stage.

What is a relevant criminal conviction?


Relevant criminal convictions are only those
• convictions for offences against the person, whether of a
violent or sexual nature,
and
• convictions for offences involving unlawfully supplying
controlled drugs or substances where the conviction concerns
commercial drug dealing or trafficking.

Convictions that are spent (as defined by the Rehabilitation of


Offenders Act 1974) are not considered to be relevant and you
should not reveal them.

Declaration

I confirm that to the best of my knowledge, the information given


on this form is correct and complete. I have read the notes for
guidance. I understand what it says and agree to abide by the
conditions set out there, which I accept as conditions of this
application.

My
signature

Date

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