Health and Learning Support Declaration

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Health and Learning Support Declaration

We require further information about your health and learning support requirements to ensure that we can fully support you at Telford College.

Please complete the below form, so our team can review your support requirements. If you would like any further information, please contact our admissions team, via the email with the link to this form.

Hidden

Student ID(Required)

Doctors details

Doctor's surgery name(Required)

Address(Required)

Post Code

Emergency contact

We will use the emergency contact you have provided on your application/enrolment form. If you would like to update your emergency contact please contact us.

Do you have/have you ever had any of the following?

Are you taking any medication on prescription from a doctor?(Required)

Yes

Please give details(Required)

Do you see a specalist doctor, counsellor or support worker?(Required)

Yes

Specalist's name(Required)

Specalist's profession(Required)

Do you have a visual impairment?(Required)

Yes

Please give details(Required)

Do you have a hearing impairment?(Required)

Yes

Please give detail(Required)

Are you supported by the Sensory Inclusion Service?(Required)

Yes

Do you suffer from asthma or chest illness?(Required)

Yes

Please give details of the type of inhaler you use, and what triggers your asthma(Required)

Do you have epilspsy?(Required)

Yes

Please give details(Required)

Do you receive treatment for depression, mental health issues, anxiety or panic attacks?(Required)

Yes

Please give details of any treatment(Required)

Do you have diabetes?(Required)

Yes

Please give details if recent onset/since childhood, and how your diabetes is controlled(Required)

Do you have a blood disorder?(Required)

Yes

Please give details(Required)

Do you suffer from eczema or skin sensitivities?(Required)

Yes

Please give details(Required)

Do you have a heart or circulatory condition?(Required)

Yes

Please give details(Required)

Do you have any joint or bone problems?(Required)

Yes

Please give details(Required)

Do you require a Personal Emergency Evacuation Plan (PEEP)?(Required)

Yes

Do you have any other health issue or disability not stated?(Required)

Yes

Please give details(Required)

Have you ever been assessed by an educational psychologist?(Required)

Yes

Have you ever been assessed by a Physiotherapist?(Required)

Yes

Have you ever been assessed by a Speach/Language Therapist?(Required)

Yes

Have you ever been assessed by CAMHS?(Required)

Yes

Have you ever been assessed by an Occupational Therapist?(Required)

Yes

Do you have any additional learning support needs, disabilities or medical conditions?

Physical disability

Mobility problems

Multiple disabilities

Profound/complex disabilities

Speech/language communication difficulty

Aspergers syndrome

ADHD/ADD

Education Health Care Plan (EHCP)

Emotional/behavioral difficulties

Moderate learning difficulty

Severe learning difficulty

Multiple learning difficulties

Other specific learning difficulty

Dyspraxia

Dyslexia

Dyscalculia

Difficulty with reading

Difficulty with writing

Autistic Spectrum Condition (ASC)

Other

Do you require wheelchair access?(Required)

Yes

Do you require transport/mobility assistance?(Required)

Yes

Extra support in school

Do/did you have any extra support at school?(Required)

Yes

Do/did you have support in class?(Required)

Yes

What support do/did you receive in class?

Teaching assistant

One to one support

Shared support

What in class support do you think you will need at Telford College

Teaching assistant

One to one support

Shared support

Do/did you have support at break/lunch times(Required)

Yes

What support do/did you receive at break/lunch times?

Personal care

Feeding

Behaviour

What support at break/lunch time do you think you will need at Telford College

Support tutor

Mentor

Behavior

Counselling

Do/did you have support a medical condition?(Required)

Yes

What condition do/did you receive support for?(Required)

What support do/did you receive for your condition?(Required)

What support for your condition do you think you will need at Telford College(Required)

Do/did you have any emotional/behavioral support?(Required)

Yes

What emotional/behavioral support do/did you receive?(Required)

What emotional/behavioral support do you think you will need at Telford College(Required)

Do/did you have access to assistive technology?(Required)

Yes

What assistive technology do/did you have access to?(Required)

What assistive technology do you think you will need at Telford College(Required)

Do/did you have access/adaptation to facilities or equipment support?(Required)

Yes

What access/adaptation do/did you receive?(Required)

What support do you think you will need at Telford College(Required)

Do/did you have exam arrangements?(Required)

Yes

What exam arrangements do/did you receive?(Required)

Reader

Scribe

Prompt

Extra time

Other

What exam arrangements do you think you will need at Telford College(Required)

Reader

Scribe

Prompt

Extra time

Other

Are you a carer for someone?(Required)

Yes

Are you a child in care?(Required)

Yes

Are you a care leaver?(Required)

Yes

Are you 18 or under and live independently?(Required)

Yes

Are you 18 and under and are a parent?(Required)

Yes

Declaration

Your information(Required)

Telford College is what's known as 'the controller' of the personal data you provide to us. We need to know your basic personal data to provide you with details regarding your interaction with Telford College it will also be used by the College's analysis services, where appropriate. We will not collect any personal data from you that we do not need to provide and oversee services to yourself. We have Data Protection procedures in place to oversee the effective and secure processing of your personal data. We will not disclose the information you entrust us with to third parties except where we have a statutory or contractual duty to do so (including to your employer, if sponsored), where you have given prior approval or where an official Telford College third-party data sharing agreement exists. Telford College will use your name and email address to inform you of our future offers and similar products or services. This information is not shared with third parties, and you can unsubscribe at any time by contacting us. We are required under UK tax law to keep your basic personal data (name, address, contact details) for a minimum of 7 years (plus current year) after which time it will be destroyed. For marketing purposes your information will be kept until you notify us that you no longer wish to receive this type of information. lf at any point you believe the information we process about you is incorrect, you can request to see this information and have it corrected or deleted. Or if you wish to raise a complaint on how we have handled your personal data, you can contact our Data Protection Officer who will investigate the matter for you, please email dpo@telfordcollege.ac.uk with full details of the complaint. More information on Telford College's Data Protection framework can be found on our website.

I agree to the college's data privacy notice

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