Access SUMMIT Logo

...supporting students
Request to Access SUMMIT for Personal Support...for use by Disability Advisers...

 

Submitted by:-

 
HEI:-

 

If Other, please specify here:-

 
Your telephone number:-

 
Your email address:-

 
On date:- (**/**/**** format please)

 
For student:-

 
Student's landline telephone number:-

 
Student's mobile telephone number:-

 
Student's email address:-

 
Student's term-time address:-  

Address Line 1

 

Address Line 2

 

Address Line 3

 

Address Line 4

 

Post-code

 
Student's home address if different:-

Address Line 1

 

Address Line 2

 

Address Line 3

 

Address Line 4

 

 

Post-code

 

 
DoB:- (**/**/**** format please)

 
Institution:-

If Other, please specify here:-

 
Course:-

 
Designation:-

 

If Other, please specify here:-

 
2006 -07 = of a

 
Current academic year started (month + year):-

 
Teaching weeks of current academic year remaining:-

 
Total number of teaching weeks for full academic year:-

 
Funding details:-

If Other, please specify here:-

 
Funding body to be specified on timesheet:-

 
Type of Support 1 requested:-

 

If Other, please specify here:-

 
Hours Support 1 is needed with schedule if known:-

E.g. 1 hour per week; 8 hours per week...

 
Please give more specific details about Support 1 & any special requirements:-

 
Where is Support 1 required? i.e. location?

 
Total value of Support 1 - in £:-

 

Type of Support 2 requested:-

If Other, please specify here:-

 
Hours Support 2 needed with schedule if known:-

E.g. 1 hour per week; 8 hours per week...

 

Please give more specific details about Support  2 & any special requirements:-

 
Where is Support 2 required? i.e. location?

 
Total value of Support 2 - in £:-

 
Type of Support 3 requested:-

If Other, please specify here:-

 
Hours Support 3 is needed with schedule if known:-

E.g. 1 hour per week; 8 hours per week...

 

 

Please give more specific details about Support  3 needed & any special requirements:-

 
Where is Support 3 required? i.e. location?

 
Total value of Support 3 - in £:-

 
 

Thank-you - please review the details you have entered and if you are satisfied everything is correct click Submit below.