Residential payments

Which type of accommodation are you applying for?*

Higher Education

Apprenticeship

What course(s) have you applied for?*

Name

First name*

Last name*

Address*

Postcode*

Email address*

Mobile Number

Date of birth*

Nationality

Sex

Female

Male

Who do you normally live with?

I live with parents/guardians

I live independently

I live under the care of social services or the local authority

Next of kin 1

Name*

What is their relationship to you?*

Primary contact number*

Alternative contact number

Email*

Next of kin 2

Name

What is their relationship to you?

Primary contact number

Alternative contact number

Email

Do you have a learning difficulty or require additional learning support?*

No

Yes

Do you have any visual or hearing impairments?*

No

Visual impairment

Hearing impairment

Visual and hearing impairment

Do you have any religious or cultural needs?*

No

Yes

Do you have any personal management/high care needs?*

No

Yes

Do you have mobility issues or a clinical need for ground floor accommodation?*

No

Yes

Do you have a repeat prescription for any of the following?

Ventolin inhalers

Anti-histamines

ADHD medication

Other controlled medication

Do you have any dietary requirements?*

No

Yes

Have you been diagnosed with any of the following medical conditions?

Physical health conditions

Mental health conditions

Non-food allergies

Do any of the above require you to have regular doctor appointments?*

No

Yes

Have you experienced seizures or blackouts in the last 2 years?*

No

Yes

Have you been vaccinated against tetanus?*

No

Yes

If you have any other ongoing health issues, state them below

Tick any of the following that apply to you

I have an unspent criminal conviction

I have a police caution issued within the last 12 months

I am on probation

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