CONFIDENTIAL
Disclosure Authorisation Form
For completion by Manchester Met University staff when a student discloses a disability to
them:
Date: 10th November 2022
Name of student: THOMAS HOBSON
Student contact details: Email or
Telephone:
Student ID number: 22514878
Staff member name, Dept and Ext No. Sonia Anderson
Complete section A or B (according to the student’s requirements) The student must sign the
form or an email from the student’s university email account must be attached to indicate
consent
Section A (If the student wishes to receive support from the Disability Service)
I have disclosed that I have a disability and would like to register with The Disability Service in order
that my disability-related needs can be assessed, and any support and adjustments implemented.
I would like: Sonia Anderson (Name of the member of staff completing this form) to forward this form
to the Disability Service on my behalf, to ask them to contact me.
Student signature Thomas Hobson Date 13/11/22
If this section is completed; please return in a sealed envelope marked “strictly confidential” to:
The Disability Service, Student Hub, Business School or email to
Section B (If the student does not wish to receive support from the Disability Service)
I confirm the support available and benefits of engaging with the Disability Service have been
explained to me. I do not wish for any action to be taken as a consequence of disclosing my disability. I
accept that this may prevent or limit disability related support that I would be eligible for. I
understand that this form will be retained by the Academic Registrar as per the University’s Retention
and Disposal Schedule and in a confidential and secure manner in accordance with the requirements
of the University’s Data Protection Policy. I am aware that I can review this decision and can choose to
contact the Disability Service at a later date.
Student signature……………………………………… Date………………………
If this section is completed, please return in a sealed envelope marked “strictly confidential” to:
Academic Registrar, Room 1.09, 2nd floor, 6 Great Marlborough Street.’
Thanks to London Metropolitan University for the template of this document and form.
Disclosure Authorisation Form
For completion by Manchester Met University staff when a student discloses a disability to
them:
Date: 10th November 2022
Name of student: THOMAS HOBSON
Student contact details: Email or
Telephone:
Student ID number: 22514878
Staff member name, Dept and Ext No. Sonia Anderson
Complete section A or B (according to the student’s requirements) The student must sign the
form or an email from the student’s university email account must be attached to indicate
consent
Section A (If the student wishes to receive support from the Disability Service)
I have disclosed that I have a disability and would like to register with The Disability Service in order
that my disability-related needs can be assessed, and any support and adjustments implemented.
I would like: Sonia Anderson (Name of the member of staff completing this form) to forward this form
to the Disability Service on my behalf, to ask them to contact me.
Student signature Thomas Hobson Date 13/11/22
If this section is completed; please return in a sealed envelope marked “strictly confidential” to:
The Disability Service, Student Hub, Business School or email to
Section B (If the student does not wish to receive support from the Disability Service)
I confirm the support available and benefits of engaging with the Disability Service have been
explained to me. I do not wish for any action to be taken as a consequence of disclosing my disability. I
accept that this may prevent or limit disability related support that I would be eligible for. I
understand that this form will be retained by the Academic Registrar as per the University’s Retention
and Disposal Schedule and in a confidential and secure manner in accordance with the requirements
of the University’s Data Protection Policy. I am aware that I can review this decision and can choose to
contact the Disability Service at a later date.
Student signature……………………………………… Date………………………
If this section is completed, please return in a sealed envelope marked “strictly confidential” to:
Academic Registrar, Room 1.09, 2nd floor, 6 Great Marlborough Street.’
Thanks to London Metropolitan University for the template of this document and form.
