university student declaration form

The Student Registry
Academic Division

Student Declaration form to be used for:

1) an application for an examination allowance on medical grounds;
2) permission to return to study following an examination allowance on medical grounds
3) permission to return to study following a period of intermission on medical grounds

DECLARATION

I confirm that I give my consent for the enclosed supporting medical evidence to be submitted and made available, on a confidential basis, to the Board of Graduate Studies and its Medical Adviser(s) (please tick as appropriate).

Yes

No

Only members of the Board of Graduate Studies and its medical adviser(s) and the College have access to the medical evidence. The medical adviser makes a recommendation based on the professional assessment of the medical evidence provided.

The University undertakes to process the information lawfully and in accordance with the Data Protection Act 1998 and will not divulge its contents to any third party or use it for any other purpose without your express consent.

I agree that my College may contact my Medical Practioner for further information (for instance to confirm that he or she has read the Board’s Guidelines for Medical Practitioners or to help ensure the continuation of any medical care or other support on my return to Cambridge.)

Yes

No

Surname:

Forename(s):

USN:

College:

Signature:

Date:

Please return this form and supporting paperwork to Dr Kate Maxwell, Secretary of the Board of Graduate Studies, The Student Registry, 4 Mill Lane or submit a completed, scanned copy by email to [e-mail]