Student ALS Disclosure Form 20 /20
Return form to: ALS Admin, Room 36A, PRC, Park Crescent PE1 4DZ, 01733 762256,
1)Student ID Number:...... Contact Number:......
2)Student Name: ...... Age:...... Date of Birth: ...... /...... /...... Gender: M/F
3)Are you under 21 and either looked after by the Local Authority or a Care provider?Y / N
4)Is English your first language? Y / N If no, state first language......
5) What is the best method of communication for you: BSL SSE MakatonLip-Reading
Deafblind ManualOther......
6) Please give us a general description of your difficulty/disability:......
7) Do you have a formal diagnosis of a learning difficulty / disability by a specialist teacher/
Educational Psychologist or other?Y /N If yes, please specify: ......
8) How does your difficulty / disability affect your learning?Vision Hearing Speech Handwriting Memory Mobility Social skills Attendance Fine/Gross motor skills Attitude Behaviour Motivation Concentration Stamina Ability to cope with change Literacy Skills Numeracy Skills Require Personal Care Study Skills Other......
9) Did/Do you currently receive support at secondary school/ college/university? Y / N
If yes, please state type / amount:......
10) Have you previously had exam access arrangements?(e.g. reader, scribe, 25% extra time)Y / N
If yes please specify......
11) Do you currently use any specialist equipment? Y / N Wheelchair (PEEP needed) Powered Manual
HoistWalking FrameSticksHearing AidRadio Mike Loop SystemTextphoneZoomtext ScannerSpeech Recognition SoftwareOther......
12) Do you have health problems?(e.g. asthma, epilepsy, mental health difficulties)
......
13) Do you take any medication?......
14) What support do you thinkyou may need at college to fully access your course and achieve your full potential?(e.g. 1:1 in class support, literacy/ numeracy support out of class, study skills support, coloured overlay, hand-outs on coloured paper, use of Alphasmart or laptop)......
I have completed this assessment for the purposes of identifying my need for additional support during my course of study. I give my consent for information on this form to be distributed (by hard copy and/ or email) to staff at Peterborough Regional College where deemed appropriate and necessary in order to support my learning. I consent to my needs/support arrangements being discussed with my parent/legal guardian if I am under 18 years of age.
I will provide any reports, documentation and relevant information relating to my learning difficulty/disability to Peterborough Regional College. I give permission for my school / college and/or any other external supporting agencies to release a copy of any assessment, report or paperwork relating to myself to Peterborough Regional College.
The information will be treated as confidential and no further transfer of personal information will take place without my consent. The supervision of and eventual disposal of this information & supplementary forms will fully comply with the Data Protection Act 1998.
Signed...... Print...... (Student) Date ...... /...... /......
Signed...... Print...... (PRC Representative)Date ...... /...... /......
To be completed by ALS staff only
Appointment date: / Appointment time: / Appointment with: / Attended: Y/N / Support RecommendedY / N
Y / N
Y / N