Disrupted Studies form - University of Sheffield
DISRUPTED STUDIES FORM
This form is for notifying the University of Sheffield of issues of a personal, social or domestic nature that have affected either your post-16 studies or any GCSE-level subjects cited in our course entry requirements. Before completing the form, please refer to guidance on the Disrupted Studies scheme available at sheffield.ac.uk/study/policies/disrupted-studies
PART 1: To be completed by the applicant
Personal information
|Title | |Forename/Given name(s) | |
|Surname/Family name | |
|Telephone number | |Email address | |
|UCAS ID/Sheffield applicant number | |
Course information
Please list the University of Sheffield course or courses which you have applied to study
|Course title | |Course code | |
|Course title | |Course code | |
|Course title | |Course code | |
Applicant statement
Please tell us about the circumstances you would like us to consider alongside the information in your UCAS application. Where appropriate provide supporting evidence (eg medical correspondence).
| |
Please pass the form to your UCAS referee to complete the second page
PART 2: To be completed by the UCAS referee
Referee information
|Name of applicant | |
|Name of referee | |
|Position | |
|Name of school/college | |UCAS school code | |
|Telephone number | |Email address | |
Referee statement
Please provide a short statement to corroborate the applicant’s account. We would welcome information about the dates/times when the circumstances occurred, the applicant’s academic trajectory and any barriers to their continuation in post-16 education.
| |
PART 3: Declarations
REFEREE DECLARATION
I confirm that the information provided on this form is a complete and accurate record and that no material information has been willingly omitted. I give my consent to the processing of this information by the University of Sheffield.
Signed.................................................................................................................... Date...........................................................
APPLICANT DECLARATION
I confirm that the information I have provided is a complete and accurate record and that no material information has been willingly omitted. I give my consent to the processing of my data by the University of Sheffield.
Signed.................................................................................................................... Date...........................................................
Please submit the completed form and any supporting evidence by email to disruptedstudies@sheffield.ac.uk or on paper to the Admissions Service, The University of Sheffield, Level 2, Arts Tower, Western Bank, Sheffield, S10 2TN, UNITED KINGDOM
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