Disability Service Registration Form

We value your privacy and we have a strong commitment to confidentiality.

The information you provide on this form will be kept within the Disability Service. It will assist us to provide a prompt and personalised response to help get you engaged in your studies as quickly as possible.

Personal Details

Information about the nature of your disability or medical condition will not be disclosed and will not appear on your academic records.

Please complete each Section. You are able to upload a copy of your Supporting Documentation at the end of this registration form.
First Name *
Preferred Name
Surname *
Date of Birth Date of Birth * / DD / MM YYYY
Please indicate below if you are a current or future student

Please indicate below if you are a current or future student Current student Future student
Student number
University Campus
Are you:

Are you: At University Accommodation Are you an international student Aboriginal or Torres Strait Islander First in Family to Study at University
Contact Information
Email (University preferred) *
Phone (mobile preferred) *
Please select your preferred contact method

Please select your preferred contact method Phone Email
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
How did you find out about us? *
Faculty
Disability/Medical Information

Please be assured that the information you provide on this form is only available to the Disability Service.
Disability/Medical condition *
If "Other" disability, please advise
Additional disability (if relevant)
Please provide details of your condition/s *
Please describe how your condition impacts on your study *
Please describe any Mobility Issues
Did you have special provisions in Year 12? *

Did you have special provisions in Year 12? Yes No
If "Yes," please upload any documentation of Year 12 provisions.

Attach Files
Have you previously studied at a tertiary institution? *

Have you previously studied at a tertiary institution? Yes No
If "Yes," please upload documentation on any special provisions or reasonable adjustments provided

Attach Files
Medical Information & Documentation

Please attach any relevant medical information. Alternatively, you can download our Supporting Documentation Form from the Disability Service website and ask your Medical practitioner to complete it.
Supporting Documentation (To be completed by a relevant practitioner)
Please upload a copy of your completed Supporting Documentation form

Attach Files
Psychological learning assessments and/or medical certificates or reports

Attach Files
Any other relevant medical documentation of your disability or medical condition from your medical practitioner.

Attach Files
Additional information

Attach Files
If you are unable to provide your relevant documents, please outline the reason below:
Additional information

Please include any other relevant information in the box below:
Other information

Disability Service Registration Form

Disability Service Registration Form

Personal Details

Contact Information

Disability/Medical Information

Medical Information & Documentation

Additional information