AccessAbility Registration Form

Step 1. To register with AccessAbiltiy please complete the registration form and consent form below. Use the submit button at the end of the form for this to be sent to AccessAbility.

First Name: *

Surname *

Preferred Name:

Pronouns:

Student Number: *

Phone: *

Phone (Option 2):

Student Email Address: *

Do you have an NDIS (National Disability Insurance Scheme) plan?

YesNoIn the process of obtaining

(For more information go to ndis.gov.au)

Program of Study: (e.g., B Arts, M Pharmacy, Open Foundation) *

Data is gathered through MyHub on students with a disability/health condition that determines federal funding allocated to the University to support students with disability/health conditions. This data is also used so that students with disability/health conditions can be granted priority allocation of their preferred timeslots for classes.

Have you indicated in MyHub that you have a disability/health condition? *

Yes No

Provide details of your disability/health condition and the impact it has on your study: *

What support/adjustments are you requesting or have been recommended by your specialist? This can also be discussed with the AccessAbility advisor at your appointment: newcastle.edu.au (search ‘AccessAbility support services’) *

Have you had support/adjustments in previous studies? If yes, please provide details:

Please provide any other information you feel is relevant that should be considered by the AccessAbility Advisor when determining your support requirements:

The University of Newcastle is subject to the Privacy and Personal Information Protection Act 1998 and the Health Records and Information Privacy Act 2002. The personal information you provide in relation to your registration will be protected in accordance with the University Privacy Management Plan and will be used by the University in order to offer you practical assistance and advice related to a disability/health condition. The support and assistance aims to assist students to meet the inherent requirements of their course whilst maintaining academic independence. By signing below, or otherwise submitting this application via your University email account, it is understood that you have read this statement and agree to the use and disclosure of your personal information as detailed in the Privacy Managment Plan. This form is fillable electronically. Full details of the University Privacy Management Plan can be found at the following link: https://policies.newcastle.edu.au/document/view-current.php?id=93

Name: *

Signature: *

Draw signature|Type signatureClear

Date *

AccessAbility Consent Form

Reasonable Adjustment Plan

As part of your registration with AccessAbility, a ‘Reasonable Adjustment Plan’ may be developed to communicate the recommended adjustments discussed and agreed upon by you and an AccessAbility Advisor. For adjustments to be put in place to minimise the impact of your condition/s on your studies, a copy of your Reasonable Adjustment Plan will need to be provided to relevant University Staff. This will include your Course Coordinators and, at times, other academic staff (lecturers, tutors) or administration staff within the School. Your Reasonable Adjustment Plan will only be shared with University staff who are directly involved in implementing your adjustments.

You can choose whether you would like AccessAbility to provide a copy of your Reasonable Adjustment Plan to relevant University staff, or if you would prefer to share this with them yourself. You can also withdraw your consent for your Reasonable Adjustment Plan to be shared by AccessAbility at any time by contacting AccessAbility@newcastle.edu.au

I, Full Name, *

Student Number: *

hereby acknowledge and agree that:

1. I have read and understood the consent information. *

I agree

2. Select one consent option: *

I consent to relevant University staff being provided a copy of my Reasonable Adjustment Plan by AccessAbility.I do not consent to relevant University staff being provided a copy of my Reasonable Adjustment Plan by AccessAbility. I understand that I will need to provide my Course Coordinators with a copy of my Reasonable Adjustment Plan at the beginning of each teaching period for my adjustments to be implemented.

Signature: *

Draw signature|Type signatureClear

Date: *

Advocate

Please complete this section if you wish to nominate someone (a family member, partner, friend or formal advocate) to speak on your behalf to AccessAbility University Staff. Please note that this is completely voluntary and offered as a way to help you to access assistance and advice from AccessAbility. You do not need to nominate anyone to speak on your behalf to AccessAbility staff.

Would you like to nominate an advocate to speak on your behalf to AccessAbility Staff? *

YesNo

By signing below,

I, (full name),

Student Number:

consent to AccessAbility staff communicating with the person listed as my advocate below for the purposes of providing me with appropriate support in relation to my participation in University programs. I further consent for my advocate and AccessAbility to share and disclose my personal and health information (which may include details of my disability, enrolment status, course load and/or my Reasonable Adjustment Plan). I understand that my advocate does not have the power to make major decisions on my behalf but may be consulted in relation to them (e.g. enrolment, withdrawal, leave). I understand that I may revoke this consent at any time by advising AccessAbility@newcastle.edu.au in writing.

Advocate Name:

Relationship to you (e.g. parent, partner, friend):

Phone number of advocate:

Email address of advocate:

Advocate Signature:

Draw signature|Type signatureClear

Student Signature:

Draw signature|Type signatureClear

Date:

For more information please contact AccessAbility: Call: (02) 4921 6622 or Email: AccessAbility@newcastle.edu.au

Save and Complete Later