/ Get Talking
Community research /
/ I would like a place on the course.
Please let me know if I can come.
/ My date of birth
/ My name
/ My address
/ My phone number
/ My email


/ My community action / Please tick if you are
an Appetite volunteer,
a member of the 1000 Lives
planning team
a Staffordshire Graduate research
student volunteer
/ My
Learning support needs / The University can support you better if we know what disability you have.
Please fill in the rest of the form.
If you need help with the form please ask.
/ My criminal record / The University needs to know if you have convictions that are not spent.
This is to make sure that you and other students and staff are safe.
Please fill in the rest of the form.
If you need help with the form please ask.
/ Disability/special needs

If you have a disability, special needs (including dyslexia or another specific learning difficulty) or a medical condition, please select the most appropriate option from the list. If you do not have a disability, special needs or a medical condition, select 'No disability'. If you do not want to give this information now, you should select 'No disability'. However, you should tell your chosen universities or colleges as soon as you receive our welcome letter.

Disability or Special Needs code

Please enter the code from the list on the next page, if you have a physical or sensory disability which may affect your studies.

Please tell us about any special needs for facilities or support you have because of your disability or medical condition.

Disability, special needs or medical condition codes:

  1. No disability
  2. You have a social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder
  3. You are blind or have a serious visual impairment uncorrected by glasses
  4. You are deaf or have a serious hearing impairment
  5. You have a long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy
  6. You have a mental health condition, such as depression, schizophrenia or anxiety disorder
  7. You have a specific learning difficulty such as dyslexia, dyspraxia or AD(H)D
  8. You have physical impairment or mobility issues, such as difficulty using your arms or using a wheelchair or crutches
  9. You have a disability, impairment or medical condition that is not listed above
  10. You have two or more impairments and/or disabling medical conditions

/ Criminal convictions

To help the universities and colleges reduce the risk of harm or injury to their students and staff caused by the criminal behaviour of other students, they must know about any relevant criminal convictions that an applicant has. Please read the following carefully.
If you have a relevant criminal conviction that is not spent, please tick the box; otherwise leave it blank.

Criminal Convictions
If you have a relevant criminal conviction, enter X in the box

Yes

If you tick the box you will not be automatically excluded from the application process. You do not need to provide any details of your conviction now. However, the university or college may ask you to provide further information at a later stage.
What is a relevant criminal conviction?
Relevant criminal convictions are only those

  • convictions for offences against the person, whether of a violent or sexual nature,

and

  • convictions for offences involving unlawfully supplying controlled drugs or substances where the conviction concerns commercial drug dealing or trafficking.

Convictions that are spent (as defined by the Rehabilitation of Offenders Act 1974) are not considered to be relevant and you should not reveal them.

/ Declaration

I confirm that to the best of my knowledge, the information given on this form is correct and complete. I have read the notes for guidance. I understand what it says and agree to abide by the conditions set out there, which I accept as conditions of this application.

/ My signature
/ Date

Please send this form back to Nicola Gratton

by post to :
Creative Communities Unit, L225, Flaxman building, College Rd, Stoke on Trent ST4 2DE

or email to: