Confidential

Disability Support Service

Registration Form

Manukau Institute of Technology is committed to supporting the participation of students with disability. If you consider your studies may be affected in some way by disability you will need to complete this form to access the available services.

Continuing students should re-register each year to ensure continuity of service.

Date: ___/____/_20___ Student ID Number (if known)

Have you registered with the Disability Support Service before? Yes ☐ No ☐

Year of first registration:

First name Ethnicity

Surname Gender Male ☐ Female ☐

Mobile Date of Birth

Email

Home No.

Emergency contact information:

Name Relationship

Phone

Course Information:

Course name

Faculty: (Please tick)Campus (Please tick)

☐Education and Social Science☐South Campus Otara

☐Business and IT☐North Campus Otara

☐Consumer Services☐Manukau Campus

☐Engineering and Trades☐Mahunga Drive Campus

☐Creative Arts☐Maritime

☐Nursing and Health Studies☐Pukekohe

Please indicate the area(s) which most closely describe your impairment:

☐Deaf ☐Specific Learning ☐Physical and or Mobility

☐Hearing ☐Medical ☐Speech

☐Blind ☐Head Injury ☐Temporary

☐Visual ☐Mental Health

Further detail if needed:

Did you identify/tick disability on your enrolment form? Yes ☐ No ☐

In the event of an emergency do you require assistance to evacuate the building? Yes ☐ No ☐

I require assistance ☐

Or

I do not require assistance at this time ☐

To be eligible for support services while at Manukau Institute of Technology, it is essential that you include supporting documentation from a doctor, therapist, or other appropriate professional with this application.

This must describe:

  1. The disability or medical condition.
  2. The impact this has on your study.
  3. The equipment and/or support services you are applying for.
  4. Whether your condition is permanent, temporary or fluctuating.

Support services cannot be provided without the required documentation. Implementation of support services will be based on a range of factors which will be discussed with you personally.

In order to best meet your needs, it may be necessary to liaise with other staff Manukau Institute of Technology from time to time. Consent from you is required to allow Disability Service staff to share your health and disability related information with staff who need to know. It is important that you complete the following:

Any Queries? Please contact Disability Support: Ph: (09) 968 7668 Mob: 027 568 7669

Email: Address: Manukau Institute of Technology, Private Bag 94006, 2240