Neurodiversity Centre student referral form

Your details
What is your full name?

First name

Last name
What is your P number?

If you are an applicant, please enter 0
What is your date of birth?
Address

Address Line 1

Address Line 2

City

County

Postcode

Country
What is your email address?
What is your phone number?
What type of DMU student are you/will you be?
Higher educationApprenticeFoundation Art studentAn applicant (I hold a firm offer at DMU and have made DMU my 1st choice)
What is the title of your course?
What faculty are you/will you be in?
ADH (Art, Design and Humanities)BAL (Business and Law)CEM (Computing, Engineering and Media)HLS (Health and Life Sciences)

If you are unsure of what faculty your course is part of, you can look it up at https://dmu.rl.talis.com/index.html?browse
Are you in the final year of your course?
YesNo

Your agreement
As a Higher Education student at DMU, I agree that:
I understand that if a disability is identified from my assessment I agree to apply for the Disabled Students’ Allowances (if eligible). If the assessment confirms a disability, and I am not in receipt of Disabled Students’ Allowance within 6 months of being assessed, I will be charged £100 towards the cost of the assessment.
I agree
I must continue to monitor my email account and read/respond to emails sent to the account.
I agree
I am registered and in attendance on the course I have provided details of.
I agree

Your agreement
As an Apprentice at DMU, I agree that:
I understand that if a Specific Learning Difference is confirmed by my formal assessment, I will be able to apply for Access to Work from my employer, and support at DMU.
I agree
I must continue to monitor my email account and read/respond to emails sent to the account.
I agree
I am registered and in attendance on the course I have provided details of.
I agree

Your agreement
As a Foundation Art student at DMU, I agree that:
I must continue to monitor my email account and read/respond to emails sent to the account.
I agree
I am registered and in attendance on the course I have provided details of.
I agree

Your agreement
As an applicant to DMU (I am a firm offer holder and DMU is my first choice), I agree that:
I must continue to monitor my email account and read/respond to emails sent to the account.
I agree

Declaration
I declare that the information I have given is correct and complete to the best of my knowledge. If incorrect information has been given then I will be required to pay the cost of the assessment(s).
I agree