Additional Learning Support Declaration of Support Needs Any information you provide will help us to organise support and provide reasonable adjustments during your time studying with us. Student Information Student Forename(s) * Student Surname * Student Number * Date of Birth * Campus * —Please choose an option—CroydonCoulsdon Email * Contact Number * If you are studying for an apprenticeship, is it * —Please choose an option—Work Based LearningDay Releasen/a Learning Support 1. Do you have any difficulties with the following ReadingWritingEnglishMathsESOLAcademic SkillsOther (please specify below) 2. In examinations, were you entitled to any of the following (Access Arrangements) Extra TimeReaderScribeWord ProcessorSeparate RoomOther (please specify below) 3. Do you consider yourself to have any of the following learning difficulties / disabilities DyslexiaADD/ADHDVisual ImpairmentPersonal care support needHearing Impairment / D/deafMental Health ConditionMobility Need including Wheelchair UserSpeech & languageAutism Spectrum ConditionOther (please specify below) 4. Do you have a medical condition that could affect your time at college? YesNo If Yes, please provide some additional information: 5. Do you have any reports on your learning difficulty, disability and/or health condition (e.g. Education, Health and Care Plan, Medical Report or Dyslexia Assessment Report)? YesNo If Yes, please send a copy of this document to us at the email address below. If you do not have a copy, please let us know where we can get one. The more information we have, the more we can help. 6. What is the name and address of your last School or College? 7. Did you receive any of the following support at your last school or college? Extra LessonsTeaching support assistantCommunication Support Worker/InterpreterSpecialist teachingSpecialist equipmentOther 8. What type of support do you think you may need at college? 9. Please provide us with details of any mobility or physical access issues as not all of our rooms are accessible 10. Please provide details of any external professionals involved (e.g. Keyworker, Social Worker, YOS Worker, CAMHS, Accommodation Manager, Personal Advisor, MH Support). Signature You must select the below box to proceed. I agree to the disclosure of the above information for the purposes of the provision of appropriate support and / or reasonable adjustments where possible. By signing this form I agree the information is accurate I accept any support offered to meI refuse to accept any support offered to me Name * Date * If completing this form on behalf of the individual named above please complete below: Name Date DATA PROTECTION Croydon College (including Coulsdon Sixth Form) will use the personal data you have included on this form for the purpose of processing your application and for planning purposes. We will do that on the basis of the contractual arrangement with the College which you are applying for. We will retain your personal data for as long as is required for that purpose. We may share your data with government departments and agencies, to the extent required and permitted by law. There is further information on the web site at https://www.croydon.ac.uk/docs/default-source/default-document-library/privacy-notice.pdf about your rights, how Croydon College protects your privacy and how to contact the Data Protection Officer if you have any concerns. If you wish to discuss this form, any aspect of learning support or reasonable adjustments, you can contact us by: Phone: 0208 686 5700 ext. 3046 Email: ALS@croydon.ac.uk
