Your Details Student Student number: name: Programme: YSJ Email: Academic Semester /Term: year: Collaborative Contact Telephone Partner: Number: (if applicable) Reason for application for extension (X as appropriate) Short Term Illness of student Illness of dependents or immediate family First application: Self-certificate once Student to attach documentary evidence with – only each year this form (e.g. GP letter, or email from Cohort Lead confirming circumstances). Subsequent applications: (Student to attach documentary evidence with this form e.g. GP letter, confirming circumstances). Bereavement Moving House Student to attach documentary evidence Student to attach documentary evidence with with this form (e.g. Death certificate, or this form (e.g. evidence of date moving house) email from Cohort Lead confirming circumstances). Registered with the Disability Advice Seeking Writing Support (not registered Team but reasonable adjustments not with Disability Unit) yet agreed Student to contact Cohort Lead as soon as Student to contact Cohort Lead as soon as possible. Supporting evidence may be required. possible. Supporting evidence may be required. Unforeseen personal circumstances Professional Interview Student to attach documentary evidence Student to attach documentary evidence with with this form (e.g. GP letter, a police this form (e.g. copy of letter inviting to crime number or insurance claim reference) interview) Inability to travel due to circumstances Time Management or multiple deadlines & lost USB beyond control stick/loss of data Student to contact Module Tutor as soon as Not acceptable as a reason for granting an extension possible. Supporting evidence may be required. Supporting Statement (please summarise your circumstances and how they have impacted your studies) Please continue the form overleaf Module(s) affected Module Published Module Tutor Revised Submission Module Title Component Code Submission Date
Your Details Student name: Student number: Programme: YSJ Email: Academic year: Semester /Term: Collaborative Partner: (if applicable) Contact Telephone Number: Reason for application for extension (X as appropriate) Short Term Illness of student First application: Self-certificate – once only each year Subsequent applications: (Student to attach documentary evidence with this form e.g. GP letter, confirming circumstances). Illness of dependents or immediate family Student to attach documentary evidence with this form (e.g. GP letter, or email from Cohort Lead confirming circumstances). Bereavement Student to attach documentary evidence with this form (e.g. Death certificate, or email from Cohort Lead confirming circumstances). Moving House Student to attach documentary evidence with this form (e.g. evidence of date moving house) Registered with the Disability Advice Team but reasonable adjustments not yet agreed Student to contact Cohort Lead as soon as possible. Supporting evidence may be required. Seeking Writing Support (not registered with Disability Unit) Student to contact Cohort Lead as soon as possible. Supporting evidence may be required. Unforeseen personal circumstances Student to attach documentary evidence with this form (e.g. GP letter, a police crime number or insurance claim reference) Professional Interview Student to attach documentary evidence with this form (e.g. copy of letter inviting to interview) Inability to travel due to circumstances beyond control Student to contact Module Tutor as soon as possible. Supporting evidence may be required. Time Management or multiple deadlines & lost USB stick/loss of data Not acceptable as a reason for granting an extension Supporting Statement (please summarise your circumstances and how they have impacted your studies) Please continue the form overleaf Module(s) affected Module Code Module Title Component Published Submission Module Tutor Revised Submission Date