Module Registration Form

MODULE REGISTRATION FORM

Return Form to:Julie Paice, FHMS, School of Biosciences

& Medicine, Student Support Office, AX Building, Guildford, Surrey, GU2 7XH

or e-mail

1. Module Details

Programme
Module Title/s
Module Dates
Module Code
How many University of Surrey module credits have you accumulated?
Previous Modules Taken:

1. Personal Details

ParticipantName / Title / First Name / Surname
Previous Surname / Date of Birth
Home Address
(Please include country of domicile)
Home Number / Mobile Number
Email Address
Emergency Contact:
Name/Address
Contact Number:
Relationship to you:
Any dietary requirements?

3. Other Personal Information

The following information is required for statutory returns that the University makes. It will not affect your enrolment for the modules you have chosen.

Please see Note sheet attached
Gender: Male / Female / Nationality:
Ethnicity / Note 1 / Enter code
Disability/Special Needs / Note 2 / Enter code
Are you in receipt of the Disabled Student Allowance (DSA) / Yes / No
Have you lived in the UK all your life? / Yes / No
Are you a UK National? / Yes / No
Are you an EU National? / Yes / No
Are you a permanent UK resident? / Yes / No
If no, are you eligible to study in the UK? / Yes / No
Do you have any criminal convictions or serious charges against you? / Yes / No
Have you ever attended a credit-bearing programme of study at:
University of Surrey / Yes / No
Another Higher Education institution (HEI) in the U.K. / Yes / No
Are you currently studying at another HEI / Yes / No
If YES, please give the name
FORMAL EDUCATION
Please give details of your highest qualification, including name of qualification, subject, year, and country obtained.

4. Signature

I undertake as a member of the University to comply with the Charter, Statutes, Ordinances and Regulations of the University.
I confirm that the information given on this form is complete and correct.
Participant Signature
Date

5. Data Protection/Ethnicity/Qualifications

DATA PROTECTION: HOW THE UNIVERSITY HANDLES PERSONAL INFORMATION ABOUT STUDENTS
It is essential the University collects and retains up-to-date personal information about its students to enable it to operate effectively and meet legal obligations. Data you enter on this form will be treated confidentially in line with the University’s Data Protection Statement and will be used by members of the University. The data is available to appropriate University staff, including Faculties and Departments, and to agents contracted by the University. It will not be disclosed to external organisations other than in accordance with the University’s Data Protection Statement –

6. Payment Options (please tick)EnclosedPlease Invoice: SelfOrganisation 

Invoices must be requested allowing time for processing within your organisation to ensure payment is made at least one month prior to module.

Name of Organisation/Self
Invoice Address
Contact Telephone No/e-mail
Purchase Order Number

Codes for use in the completion of the Registration Form

EthnicityPlease tick one box from the following:
White (10) / Chinese (34)
Black or Black British – Caribbean (21) / Other Asian Background (39)
Black or Black British – African (22) / Mixed – White and Black Caribbean (41)
Other Black background (29) / Mixed – White and Black African (42)
Asian or Asian British - Indian (31) / Mixed – White and Asian (43)
Asian or Asian British – Pakistani (32) / Other Mixed Background (49)
Asian or Asian British – Bangladeshi (33) / Other Ethnic Background (80)
NB: Information relating to ethnicity is collected solely for use in statistical analysis. The data will be subject to strict confidentiality safeguards and material drawn from student records will only be in the form of tabulations.

Disability

Code / Title / Description
A / No Disability / No Disability
B / Asperger’s / other Autistic Spectrum Disorder / Social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder
C / Blind / Partially Sighted / Blind or have a serious visual impairment uncorrected by glasses
D / Deaf / Hearing Impairment / Deaf or have a serious hearing impairment
E / Long Standing Illness / Long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease or epilepsy
F / Mental Health Condition / Mental health condition, such as depression, schizophrenia or anxiety disorder
G / Specific Learning Difficulty eg dyslexia / Specific learning difficulty such as dyslexia, dyspraxia or AD(H)D
H / Physical Impairment / Mobility Issues / Physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
I / Disability Not Listed Above / Disability, impairment or medical condition that is not listed above
J / Multiple Disabilities / Two or more impairments and/or disabling medical condition

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