Disability / Learning difficulty Do you consider yourself to have a disability and / or learning difficulty? Please tick the appropriate box. None Moderate learning difficulties □ □ □ Deaf or hearing impairment Severe learning difficulties □ □ □ Visual Impairment Dyslexia □ □ □ Disability affecting mobility Dyscalculia □ □ □ Mental ill health Multiple learning difficulties □ □ □ Profound / complex disability Other specific learning difficulty □ □ □ Unseen disability or medical condition Emotional / behavioural difficulty □ □ □ Other physical disability Temporary disability after illness □ □ □ Multiple disabilities □ □ - Leave to Remain Please tick the box which best describes your current status in the UK Refugee Asylum seeker Refugee status + indefinite leave to remain (ILR) Awaiting a decision on application for □ □ refugee status Refugee status + 5 years indefinite leave to remain Refused Asylum Seeker - application for refugee □ □ status (ILR) has been denied Discretionary leave to remain (DLR) □ Humanitarian Protection (HP) □ Other details I am a care leaver. □ □ I am a carer (a carer is someone who, without payment, provides help and support to a friend, neighbour □ □ or relative who could not manage otherwise because of frailty, illness or disability ) How did you hear about the Sanctuary Award at the University of Chester? Section 4 Referee’s supporting statement – See guidance note 5 Student’s details (Student to complete. Please clearly) Name: Phone: Referee’s details (Referee to complete. Please print clearly) Name: Role in organisation:
Disability / Learning difficulty Do you consider yourself to have a disability and / or learning difficulty? Please tick the appropriate box. □ □ None □ Moderate learning difficulties □ □ Deaf or hearing impairment □ Severe learning difficulties □ □ Visual Impairment □ Dyslexia □ □ Disability affecting mobility □ Dyscalculia □ □ Mental ill health □ Multiple learning difficulties □ □ Profound / complex disability □ Other specific learning difficulty □ □ Unseen disability or medical condition □ Emotional / behavioural difficulty □ □ Other physical disability □ Temporary disability after illness □ □ Multiple disabilities Leave to Remain - Please tick the box which best describes your current status in the UK Refugee Asylum seeker □ Refugee status + indefinite leave to remain (ILR) □ Awaiting a decision on application for refugee status □ Refugee status + 5 years indefinite leave to remain □ Refused Asylum Seeker - application for refugee status (ILR) has been denied □ Discretionary leave to remain (DLR) □ Humanitarian Protection (HP) Other details □ □ I am a care leaver. □ □ I am a carer (a carer is someone who, without payment, provides help and support to a friend, neighbour or relative who could not manage otherwise because of frailty, illness or disability ) How did you hear about the Sanctuary Award at the University of Chester? Section 4 – Referee’s supporting statement See guidance note 5 Student’s details (Student to complete. Please clearly) Name: Phone: Referee’s details (Referee to complete. Please print clearly) Name: Role in organisation:
Sanctuary%20Award%20Application%202017.docx